a. OSHA Compliance Manual with Table of Contents

With the Occupational Safety and Health Act of 1970, Congress created the Occupational Safety and Health Administration (OSHA) to assure safe and healthful working conditions for working men and women by setting and enforcing standards and by providing training, outreach, education and assistance. The attached manual template provides a reference to the OSHA Regulations and Standards and provides a means of documenting and educating physicians and staff on your practice’s policies and procedures in relation to OSHA Regulations and Standards. The entire manual should be reviewed and customized to represent the actual policies and procedures applicable to your practice.

OSHA COMPLIANCE MANUAL

BLOODBORNE PATHOGENS EXPOSURE CONTROL PLAN.............................................................1

BLOODBORNE PATHOGENS EXPOSURE CONTROL POLICY.......................................................11

OSHA COMPLIANCE ANNUAL CHECKLIST.....................................................................................15

SHARPS SAFETY DEVICES TRIALED YEAR____________........................................................17

SHARPS DEVICE EVALUATION FORM..............................................................................................18

SHARPS SAFETY SURVEY CHECKLIST.............................................................................................19

INFORMED CONSENT FOR HEPATITIS B VACCINE.......................................................................20

INFORMED REFUSAL FOR HEPATITIS B VACCINE........................................................................21

OCCUPATIONAL EXPOSURE INJURY/INCIDENT REPORT............................................................22

FOLLOW-UP TO EXPOSURE/INJURY/INCIDENT REPORT..............................................................23

JOB RISK DETERMINATION FORM....................................................................................................24

EXPLANATION OF AND CONSENT OR DECLINE FOR HUMAN IMMUNODEFICIENCY VIRUS (HIV) AND HEPATITIS B VIRUS TESTING OF SOURCE INDIVIDUAL FOLLOWING EMPLOYEE EXPOSURE..............................................................................................................................................25

PHYSICIANS/INFORMANT’S CERTIFICATION.................................................................................26

EMPLOYEE HEALTH HISTORY...........................................................................................................27

EMPLOYEE INFORMED REFUSAL OF POST EXPOSURE MEDICAL EVALUATION..................28

SUMMARY LOG OF OCCUPATIONAL PERCUTANEOUS SHARPS INJURIES..............................29

WORK RELATED SHARPS INJURY STATISTICS..............................................................................30

BLOODBORNE PATHOGENS STANDARD PRE-TEST......................................................................31

BLOODBORNE PATHOGENS STANDARD POST-TEST....................................................................32

HAZARD COMMUNICATION PLAN....................................................................................................35

HAZARD COMMUNICATION POLICY................................................................................................37

HAZARD COMMUNICATION STANDARD PICTOGRAM................................................................46

LISTING OF HAZARDOUS CHEMICAL SUBSTANCES....................................................................47

EMPLOYEE INFORMED REFUSAL OF POST ACCIDENT/INJURY- (NON PATHOGEN EXPOSURE).............................................................................................................................................48

EMPLOYEE INITIAL AND REFRESHER TRAINING - BLOODBORNE PATHOGENS AND HAZARD COMMUNICATION...............................................................................................................49

ELECTRICAL SAFETY CONTROL PLAN............................................................................................50

ELECTRICAL SAFETY POLICY............................................................................................................51

MONTHLY ELECTRICAL HAZARD INSPECTION CHEKLIST.........................................................53

ERGONOMICS CONTROL PLAN..........................................................................................................54

ERGONOMICS POLICY.........................................................................................................................55

GENERAL ERGONOMICS RISK FACTOR CHECKLIST....................................................................59

EMPLOYEE ERGONOMIC INJURY RISK ASSESSMENT SURVEY.................................................60

ERGONOMIC SAFETY SURVEY RESULTS........................................................................................62

WORKPLACE VIOLENCE CONTROL PLAN.......................................................................................63

VIOLENCE IN THE WORKPLACE POLICY.........................................................................................64

WORKPLACE VIOLENCE SURVEY.....................................................................................................69

VIOLENCE IN THE WORKPLACE SURVEY RESULTS.....................................................................71

VIOLENCE IN THE WORKPLACE ASSESSMENT..............................................................................72

WORKPLACE VIOLENCE INCIDENT REPORT..................................................................................76

TUBERCULOSIS EXPOSURE CONTROL PLAN.................................................................................77

TUBERCULOSIS EXPOSURE CONTROL POLICY.............................................................................84

EMPLOYEE PPD TESTING FORM........................................................................................................94

EMPLOYEE TB EXPOSURE POTENTIAL AND RISK DETERMINATION FORM...........................95

EMPLOYEE TB EXPOSURE POTENTIAL AND RISK DETERMINATION.......................................97

TB OCCUPATIONAL EXPOSURE INJURY/INCIDENT REPORT......................................................98

EXPLANATION OF AND CONSENT OR DECLINE FOR TB TESTING OF SOURCE INDIVIDUAL FOLLOWING EMPLOYEE EXPOSURE................................................................................................99

PRACTICE TB RISK DETERMINATION FORM................................................................................100

PRACTICE TB RISK DETERMINATION CRITERIA FORM.............................................................101

TB STANDARD POST TRAINING PROGRAM TEST........................................................................104

TB PRE/POST TRAINING TEST ANSWER KEY................................................................................106

EMPLOYEE INITIAL AND REFRESHER TRAINING RECORD- MYCOBACTERIUM TUBERCULOSIS TRAINING...............................................................................................................107

NEW REPORTING REQUIREMENTS.................................................................................................109

BLOODBORNE PATHOGENS EXPOSURE CONTROL PLAN

Occupational exposure is defined by the Federal Register as “reasonably anticipated skin, eye, mucous membrane, or parenteral contact with blood or other potentially infectious material; that may result from the performance of employee’s duties. This manual is designed as a means to educate staff and physicians on methods of exposure prevention and to deliver standard procedures to follow when exposure to the Hepatitis B virus (HBV), or AIDS (HIV), or other potentially infectious material (OPIM) occurs.

This manual shall be available at the worksite for the employee to access and reference. A copy may be requested by the employee and provided by the employer within 15 days of the request. An employee covered by this exposure control plan is defined as any full-time, part-time, temporary, contract or per diem employee.

PROGRAM ADMINISTRATION

Green Hills Direct Family Care is responsible for the implementation of the Exposure Control Plan. Green Hills Direct Family Care will maintain, review and update the Exposure Control Plan at least annually and whenever necessary to include any new or modified tasks or procedures.

When a new employee is hired or an existing employee changes jobs or assumes tasks not previously done, the following process will take place to ensure that they have been trained in the appropriate work practice controls:

The employee’s job classification and the tasks and procedures that they will perform will be evaluated in order to identify positions where occupational exposure is likely to occur.

Employee will be trained in work practice controls associated with the new job classification.

Those employees who are determined to have occupational exposure to blood or OPIM must comply with the procedures and work practices outlined in this document and by OSHA Standard, 29 CFR 1910.1030.

EXPOSURE DETERMINATION

OSHA requires employers to perform an exposure determination concerning which employees may incur occupational exposure to blood or other potentially infectious materials. Potential exposure includes but is not limited to: patient contact; cleaning of equipment, instrumentation or soiled areas; and all other situations of care of service when a potential may exist for exposure. This exposure determination is required to list all job classifications in which all employees have occupational exposure. Additionally, a list of job classifications should be included in which some employees have occupational exposure along with the specific tasks and procedures in which occupational exposure occurs for those specific classifications.

ENGINEERING AND WORK PRACTICE CONTROLS

Standard Precautions will be observed at this practice in order to prevent contact with blood or other potentially infectious materials. All body fluids such as blood, urine, feces, wound drainage, sputum, etc., and other potentially infectious material will be considered infectious regardless of the perceived status of the individual. Biological hazard signs will be used to

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signify an actual or potential presence of a biohazard and to identify equipment, containers, rooms, and materials or combinations thereof; which contain or are contaminated with, viable hazardous agents.

Standard Precautions will be used when handling specimens. Specimens of blood or other potentially infectious material shall be placed in a biohazard labeled container which prevents leakage during the collection, processing, storage, and transport of the specimen. Any contamination that occurs outside of the primary container shall require placement of the original container into a secondary container, and is labeled or color-coded appropriately. All containers with potentially infectious material shall be color-coded (orange, orange-red, or red) or labeled with the biohazard symbol.

SHARPS INJURY PREVENTION PROGRAM

It is the policy of Green Hills Direct Family Care to maintain an active Sharps Injury Prevention Program. The program will address the use of appropriate engineering and work practice controls for sharps safety, evaluate and select sharps injury prevention devices for use, implement measures for reporting sharps injuries and sharps injury hazards, and educate and train employees on sharps injury prevention.

In the hierarchy of sharps injury prevention, the first step whenever possible is to either reduce or eliminate the use of needles and other sharps. The second step is to isolate the hazard, protecting an otherwise exposed sharp, through the use of an engineering control. The following engineering controls will be utilized at this practice:

Use of sharps with engineered sharps injury protection shall be utilized whenever possible for activities such as; withdrawing body fluids, accessing a vein or artery, administering medications or other fluids, and/or other procedures involving the potential for occupational exposure to blood borne pathogens due to percutaneous injuries from contaminated sharps.

Use of retractable, protective sheath or self- resheathing, self- blunting or hinged re-cap needles to administer local anesthetics and other injectable medications whenever possible. Recapping of contaminated needles or other sharps without the above safety technology is prohibited unless no other alternative is available. In that instance, the one handed recapping technique is acceptable.

Sharps containers will be identifiable, closable, and labeled with the biohazard symbol; sized appropriately and with a full line that is readily visible; puncture resistant and leak proof; and maintained upright when in use.

A sharps container will be located close to point of use and in each patient care area. Sharps containers will be replaced routinely and whenever necessary to prevent over filling. Blood tube holders with engineered sharps protection will be single use only, with disposal

upon activation of safety feature as a single unit after each blood draw.

When these strategies are unavailable or do not provide total protection, the focus must go to work practice controls and the use of personal protective equipment. The following work practice controls will be utilized at this Green Hills Direct Family Care:

Adopt and incorporate safe habits into daily work activities when preparing and using sharps devices, practice and become familiar with the mechanism of the safety devices before incorporating them into your daily routine.

Allow for adequate lighting and space when in the presence of sharps devices.

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Keep visual contact of sharps devices when in use, be aware of other staff members in the area when using sharps devices, keep sharps pointed away from user.

Keep track of and account for all sharps devices throughout their use. Bending, shearing, breaking off of or removing contaminated needles is prohibited. Needles

are expected to be used and immediately discarded into accessible sharps containers. When using engineered sharps injury prevention devices, activate the safety feature as soon as procedure is completed.

Use two pairs of gloves during invasive procedures whenever possible. There is evidence that double gloving can reduce the risk of exposure to blood and body fluids, if the outer glove is punctured, by as much as 87%.

During cleanup, transport reusable sharps in a closed container and secure the container to prevent spills.

When disposing of sharps keep hands behind the sharps and never put hands or fingers into sharps container.

When disposing of sharps with attached tubing, maintain control of both tubing and the sharps device, always be aware that the attached tubing can recoil and cause injury.

Review of engineering and work practice controls will be performed and documented in the Exposure Control Plan at least annually to identify any new procedures, products, or technology that would further eliminate or minimize the potential for biohazard exposure in the workplace. The review of engineering controls will include the use of devices with engineered sharps injury protection and needless systems whenever possible. This identification, evaluation, and selection of effective engineering and work practice controls shall be accomplished with solicitation of input from non-managerial employees responsible for direct patient care. This Practice will establish and maintain a sharps injury log for the purpose of recording percutaneous injuries from contaminated sharps. This log will be utilized as a source of data for use in analyzing processes involving potential exposure to sharps injury. This data will be evaluated to determine opportunities to minimize or eliminate sharps injury risks. A sharps injury log will be established and maintained for every employee incident which involves occupational blood borne pathogen exposure involving percutaneous injury from a contaminated sharp. This log will remain confidential and be maintained in an area that provides security of these records. The log will capture the following information for each incident:

the type and brand of device involved in the incident the presence or lack of a sharps injury prevention feature the department or work area where the exposure incident occurred explanation of how the incident occurred

The sharps injury log will be kept in such manner as to comply with 29 CFR 1910.1030 (h) (5) (i) and 29 CFR 1904.6 and to protect the confidentiality of the injured employee. The sharps injury log shall be maintained for a period of five (5) years.

Employees will be educated on the Sharps Injury Prevention Program during the initial orientation process and with the annual blood borne pathogens training required by OSHA. Training will occur with the introduction of any new engineered sharps injury protection devices. Training records will include the following information:

The dates of the training session The contents or summary of the training sessions

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The names and qualifications of the person(s) conducting the training The names and job titles of all persons attending the training sessions

Training records will be maintained for three years from the date on which the training occurred. Employee training records are not considered confidential and will be provided to the employee within 15 working days of request.

PERSONAL PROTECTIVE EQUIPMENT

Personal protective equipment (PPE), such as gloves, gowns, masks, and eye protection, shall be provided to employees in appropriate sizes and housed in accessible locations. This includes any alternative equipment (i.e., latex-free gloves, powder-less gloves, etc.) that may be required due to an employee’s allergy to standard equipment. All supplied PPEs shall provide a reasonable barrier to blood or OPIM appropriate for the situation in which exposure of skin, eyes, mouth or other mucous membranes to blood or OPIM is anticipated. All PPEs provided by the employer shall be cleaned, laundered, and disposed of by the employer. All employees will be trained on the appropriate situations for and proper use of available PPEs.

HAND HYGEINE

Hand washing facilities must be available to employees who incur exposure to blood or other potentially infectious materials. Employees shall perform appropriate hand hygiene immediately or as soon as feasible after removal of gloves or other personal protective equipment. Employees shall wash their hands and other skin with soap and water or flush mucous membranes with water immediately, or as soon as possible following contact of these areas with blood or other potentially infectious materials. If hand washing facilities are not available, alternative hand hygiene methods (antiseptic hand cleaner or towelettes) may be used as an interim method followed by appropriate hand washing as soon as feasible.

GLOVES

Gloves shall be worn when it can be reasonably anticipated that the employee may have contact with blood or other potentially infectious materials, mucous membranes, and/or non-intact skin, especially when performing vascular access procedures and when handling or touching contaminated items or surfaces. Disposable (single use) gloves such as surgical or examination gloves shall be replaced as soon as practical when contaminated or as soon as feasible if they are torn, punctured, or when their ability to function as a barrier is compromised. Disposable (single use) gloves will not be washed or decontaminated for reuse. When removed, gloves shall be placed in an appropriate container for disposal. Gloves should be changed between each patient contact. Utility gloves may be utilized and then decontaminated for reuse if the integrity of the glove is not compromised. However, they must be discarded if they are cracked, peeling, torn, punctured, or exhibits other signs of deterioration or when their ability to function as a barrier is compromised

EYE WASH STATIONS

Eye wash stations will be provided throughout the practice in accordance with OSHA Standard 1910.151(c) which states: :Where the eyes or body of any person may be exposed to injurious corrosive materials, suitable facilities for quick drenching or flushing of the eyes and body shall be provided within the work area for immediate emergency use”. ANSI Z358.1-2009 standard

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goes on to state that eyewash stations will be supplied with tepid water. ANSI defines "tepid water" as "A flushing fluid temperature conducive to promoting a minimum 15 minute irrigation period. A suitable range is 16-38°C (60-100°F)". These eye wash stations will be located within an accessible location that requires no more than 10 seconds to reach and within a travel distance of no more than 55-60 feet. The activation of the station must be able to be performed with one hand and once activated the water flow must be continuous, leaving both hands free.

Bottled Eyewash Units are considered to be supplemental equipment only. These types of flushing units do not meet ANSI's requirements for Eyewash stations and should not be used as an alternative to a 15 minute flushing station. The ANSI Z358.1-2009 standard states, "A personal wash unit may be kept in the immediate vicinity of employees working in a potentially hazardous area. The main purpose of these units is to supply immediate flushing. With this accomplished, the injured individual should then proceed to a plumbed or self-contained Eyewash and flush the eyes for the required 15-minute period."

Signs to designate the location of each eye wash station will be placed so that it is easily visible within the areas served by the emergency equipment. Eye pieces will be covered, unless in use, to prevent contamination. Eye wash stations will be flushed weekly for a minimum of 3 minutes. In-servicing will include the location and proper use of the eye wash stations for all employees.

CONTAMINATED SURFACES

Contaminated work areas shall be cleaned immediately after completion of a procedure, or as soon as feasible after any spill of blood or other potentially infectious material. All procedures involving blood or OPIM shall be performed in such a manner as to minimize splashing, spraying, spattering, and generation of droplets of these substances. Gloves shall be worn when cleaning any contaminated surfaces. These surfaces shall be cleaned and wiped down with an “appropriate disinfectant.”

Gross contamination of surfaces or equipment shall be cleaned with soap and water prior to use of disinfectant. “Appropriate disinfectants” to be used include a diluted bleach solution, a diluted bleach solution and EPA-registered tuberculocides, sterilants, or products registered against HIV/HBV. Any broken glassware which may be contaminated will not be picked up directly with the hands, but by using a dustpan and broom, and should be placed in a puncture-resistant container.

RECEPTACLES

Any laundry (i.e., patient gowns, linens, etc.) which becomes contaminated with blood or OPIM shall be placed in appropriate receptacles (bags or containers). These receptacles shall prevent leaking of fluids to the exterior and be color-coded (red) or labeled as “biohazard” to identify their potential or actual contamination with blood or OPIM. This indicates to staff that the use of standard (universal) precautions is required for subsequent handling of the receptacle and its materials.

REGULATED MEDICAL WASTE DISPOSAL

Hazardous material is defined as any substance that can burn, explode, react violently or cause injury or harm to people, property or the environment during transport. Regulated medical waste

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is classified under hazard class 6.2 of the Department of Transportation (DoT) because of its potential to transmit disease to humans.

Batteries that contain cadmium, lead, or silver must be disposed of as hazardous waste. Any product that contains mercury must be disposed of as hazardous waste.

All regulated medical waste shall be identified by the biohazard symbol. All regulated medical waste (liquid or semi-liquid blood or other potentially infectious materials; contaminated items that would release blood or other potentially infectious materials in a liquid or semi-liquid state if compressed; items that are caked with dried blood or other potentially infectious materials and are capable of releasing these materials during handling; contaminated sharps; and pathological and microbiological wastes containing blood or other potentially infectious materials.) shall be placed in red-bagged containers. All containers/receptacles intended for reuse shall be decontaminated on a regularly scheduled basis or cleansed/decontaminated immediately if there has been evidence of visible contamination.

The practice will contract with a waste disposal company for the proper removal and disposal of all regulated medical waste that the Practice generates. Any staff member that disposes of regulated medical waste and infectious materials inside red biohazardous bags or sharps containers will be educated on appropriate “Hazmat Training” as defined by the DOT. This training will occur within 90 days of hire and annually along with Blood borne pathogens inservice.

It is the responsibility of the contracted medical waste vendor to provide the practice with appropriate containers that meet the DOT packaging requirements for proper transport and disposal of regulated medical waste. Packaging requirements include:

1. All red biohazardous bags are required to be closed by twisting and tying a square knot or by folding the twist over itself and taping the red bag closed

2. Red plastic biohazard bags are required to have a minimum thickness of 1.5 mil3. The lid to the medical waste container supplied must be snapped closed prior to pick up. The

lid is required to be on the container once there is medical waste inside of the tub4. There is a maximum weight limit per size of vendor container as follows: 35 lbs. for 10

gallons; 53 lbs. for 20 gallons; 90 lbs. for 44 gallons.5. The container supplied by the vendor must have the following markings required by the DoT:

The universal biohazard symbol The word “Biohazard” The proper shipping name- “Regulated Medical Waste” The UN number “UN3291” The maximum weight allowed for the container UN specification markings for shipping infectious materials Shippers address

6. A tracking document is to be filled out by the regulated medical waste vendor each time a pickup of medical waste is performed. The tracking document shall be signed by designated personnel at the Practice who have completed proper “hazmat training.”

PHARMACEUTICAL WASTE

The disposal of pharmaceuticals and their components is regulated by federal and local regulations and laws. The Environmental Protection Agency under the Resource Conservation

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and Recovery Act (RCRA) mandates proper disposal of any drug that meets the criteria for being hazardous. In general about 5% of pharmaceuticals are considered hazardous.

The Practice will review their pharmaceutical inventory list utilized at the practice to determine if any are listed as RCRA pharmaceuticals. Because of the complexity of hazardous pharmaceutical waste disposal, pharmacy consultation may be necessary to ensure compliance. To be considered an RCRA hazardous waste pharmaceutical the medication must first be considered a solid waste, and then it must either be specifically listed under the F,K,P or U list and/or it must exhibit a hazardous waste characteristic. A hazardous waste characteristic is defined as being ignitable, corrosive, reactive, or toxic. A current list of all RCRA pharmaceuticals can be found at 40 CFR § 261.33. If the Practice uses a medication that meets the criteria of an RCRA medication it will be disposed of following the required methods set forth by the regulated medical waste vendor with which they are contracted.

Pharmaceuticals that are not currently regulated under RCRA are often called non-RCRA pharmaceuticals. Best practices encourage the proper disposal and removal of non RCRA pharmaceuticals by an approved regulated medical waste vendor. Green Hills Direct Family Care will follow this practice. Dedicated pharmaceutical containers, which can be supplied by the Practice regulated medical waste vendor, will be utilized to dispose of all non-RCRA pharmaceuticals.

HEPATITIS B VACCINE

The hepatitis B vaccine is available and will be offered and/or provided to all unvaccinated employees whose job description involves rendering assistance in any situation involving the presence of blood and/or OPIM. This vaccine will be offered, at no cost to the employee, within ten (10) working days of their initial assignment to the work area involving the potential for occupational exposure and after appropriate education. The appropriate education will include information on the efficacy, safety, method of administration, and the benefits of receiving the hepatitis B vaccine. The hepatitis B vaccine administration will be performed by or under the supervision of a licensed physician or other licensed healthcare professional during normally scheduled employee work hours and at a reasonable facility location. Employees who decline the hepatitis B vaccine will sign a waiver stating their decision to do so. Employees who initially decline the vaccine but then later desire to receive the vaccination series may have the vaccine provided at no cost to the employee. Employees who have previously received the hepatitis B vaccine series, have proven antibody immunity to the virus, and/or should not receive the vaccine secondary to medical reasons may provide documentation of this information to their employer. Employees can refuse pre-vaccination screening for antibody status and request vaccination regardless of previous vaccination or current immunity status. If a routine booster dose of hepatitis B vaccine is recommended by the U.S. Public Health Service at a future date, such booster dose(s) shall be made available to employees in accordance with the above procedure.

POST-EXPOSURE EVALUATION AND FOLLOW-UP

An “exposure incident” is defined by OSHA as a specific eye, mouth, other mucous membrane, non-intact skin, or parenteral contact with blood or OPIM that results from the performance of an employee’s duties. When an “exposure incident” occurs, it should be reported to Practice Administrator before the end of the work shift during which the “exposure incident” occurred.

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All employees who incur an “exposure incident” will be offered post-exposure evaluation, prophylaxis, and follow-up in accordance with the OSHA Standard 1910.1030. This process will involve:

1. Documentation of the names of all employees involved in rendering assistance during the incident.

2. Documentation of the time and date of the incident.3. Documentation of the route of exposure and the circumstances under which the exposure

incident occurred.4. Documentation of the identification of the source individual, when feasible.5. Obtaining consent from the source individual to be tested for HIV/HBV infectivity. If

consent is not obtained, the employer shall establish that legally required consent cannot be obtained.

6. Providing the results of the testing of the source individual to the exposed employee and informing the employee of the applicable laws and regulations concerning disclosure of the identity and infectious status of the source individual.

7. Collecting and testing the exposed employee’s blood for HIV/HBV serological status. If the employee consents to baseline blood collection, but does not at the time give consent for HIV testing, the sample will be preserved for 90 days to allow the employee to decide if the blood should be tested for HIV serological status.

8. Offering all unvaccinated employees involved in the exposure incident post-exposure prophylaxis in accordance with the current recommendations of the U.S. Public Health Service within 24 hours of the exposure incident.

9. Offering appropriate counseling to the employee concerning precautions to take during the post-exposure period.

10. Evaluating the exposed employee for any subsequently reported illnesses relative to the exposure incident.

HEALTHCARE PROFESSIONAL EVALUATION

A written opinion shall be obtained from the healthcare professional who evaluates the employees for this practice following an exposure incident. A copy of the written opinion will be provided to the exposed employee within 15 working days of completion of the original evaluation. This written opinion shall not refer to any personal medical information of the employee. The opinion shall be limited to:

1. Indication of the need for and/or administration of the hepatitis B vaccine.2. Notation that the employee has been informed of the evaluation results.3. Notation that the employee has been told about any medical conditions resulting from

exposure to blood or other potentially infectious materials.4. Information provided to all healthcare professionals responsible for evaluating employees

after an exposure incident will have the following information available: A copy of OSHA Regulation 29 CFR 1910.1030 Blood borne Pathogens; A description of the exposed employee's duties as they relate to the exposure incident; Documentation of the route(s) of exposure and circumstances under which exposure

occurred; Results of the source individual's blood testing if available; and All medical records relevant to the appropriate treatment of the employee including

vaccination status.

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TRAINING

Training for employees will be conducted or provided by the employer:

1. Prior to or at the time of initial assignment of the employee to tasks where occupational exposure may occur

2. Within 90 days to the employee after an effective date for any changes to the standard3. At least annually to the employee thereafter. The employer will provide re-training to the

employer when any changes in work practice controls or procedures occur, which could affect occupational exposure. Training for employees will include the following: General explanation of the epidemiology and symptoms of blood borne diseases Modes of transmission of blood borne pathogens Copy and explanation of OSHA 29 CFR Standard 1910.1030 (Blood borne Pathogens) Explanation of the Exposure Control Plan and the means by which the employee can

obtain a copy of the written plan Types of and methods for recognizing procedure and/or tasks which may involve

exposure to blood or OPIM Explanation of the use and limitations of engineering control methods and work practices

which will be used Information of the types, proper use, location, removal, handling, decontamination and/or

disposal of PPE’s. Information on the Hepatitis B vaccine program Identification of signs and labels used to identify infectious or potentially infectious

materials Information on the appropriate actions to take and persons to contact in an emergency

involving blood and OPIM, including the method of reporting the incident and the medical follow-up that will be made available.

Explanation of the procedure to follow for post-exposure evaluation, prophylaxis, and follow-up

Opportunity for interactive questions and answers with the person conducting the training session.

Training records shall include: The dates of training The contents or summary of the training program The names and qualifications of the person(s) conducting the training sessions The names and job titles of the persons attending the training sessions

RECORDKEEPING

The employer shall establish and maintain an accurate and confidential record for each employee with an occupational exposure. These records will be made available to OSHA upon request.

The employer will comply with all recordkeeping requirements as stated in OSHA standard 29-CFR Part 1904. All privacy cases will be documented as such.

In accordance with the recordkeeping requirements, the employer shall establish and maintain an accurate and confidential record for each employee with an occupational exposure that shall include:

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1. Name and social security number of employee2. Copy of employee’s hepatitis B vaccination status including the dates of vaccination.3. Documentation of the employee’s training status.4. A description of the employee’s duties as they relate to the exposure incident5. Documentation of the route(s) of exposure and circumstances under which the exposure

occurred including: location of the exposure incident procedure being performed at the time of the exposure engineering controls in use at the time of the exposure work practices followed a description of any devices used during the exposure incident any PPEs in use at the time of the exposure

6. Copy of test results of examinations, medical testing ordered, and follow-up procedures (consent must be obtained from exposed employee for employer access to HIV/HBV serological testing result documentation)

7. Employer’s copy of the healthcare professional’s written opinion

The employer will use OSHA forms 300, 300A and 301 for documenting any work-related illnesses and injuries experienced by their employees at this Practice.

The employer shall ensure that employee medical records are kept confidential and shall not be disclosed or reported to any person within or outside of the workplace without the express written consent of the employee except as required by the OSHA standard or law.

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BLOODBORNE PATHOGENS EXPOSURE CONTROL POLICY

POLICY

It is the policy of Green Hills Direct Family Care to provide guidelines for health care workers and patients to minimize the contact with all real and potential contamination found in blood or other potentially infectious materials (OPIM) in accordance with the Centers for Disease Control and the Occupational Safety and Health Administration.

RESPONSIBILITIES

The health care worker is responsible for containing all body fluids and donning protective attire whenever potential contact with patient body fluids (i.e., blood, urine, mucous membranes, tissue, etc.) is anticipated.

Practice staff is responsible for adhering to the Exposure Control Plan including the use of available sharps injury protection devices and the use of personal protective equipment (PPE). All personal protective equipment will be removed prior to leaving the work area. When personal protective equipment is removed it will be done in a fashion to prevent employee contact with the infectious material and then placed in an appropriately designated container for storage, washing, decontamination or disposal.

Green Hills Direct Family Care will be responsible for providing all supplies and equipment needed for carrying out these precautions. The organization will maintain an active Sharps Injury Prevention Program; provide the staff with sharps injury prevention devices whenever possible; and review at least annually, the engineering and work practice controls utilized at the Practice. The organization will clean, launder, and dispose of personal protective equipment at no cost to the employee. Also, repairs or replacements of PPEs will be provided at no cost to the employee.

EQUIPMENT

Gloves, gowns, face shields, protective eyewear, masks, aprons, mouth to mask resuscitation devices, biohazard trash bags, linen bags, disinfectant/germicide, washer/decontaminator. Gloves should be worn when it can be reasonably anticipated that the employee may have hand contact with blood, OPIM, mucous membranes, and/or non-intact skin, especially when performing vascular access procedures and handling or touching contaminated items or surfaces.

1. Disposable (single use) gloves such as surgical or examination gloves will be replaced as soon as practical when contaminated or as soon as feasible if they are torn, punctured, or when their ability to function as a barrier is compromised.

2. Disposable (single use) gloves will not be washed or decontaminated for reuse.3. Utility gloves may be utilized and then decontaminated for reuse if the integrity of the glove

is not compromised. However, they must be discarded if they are cracked, peelings, torn, punctured, or exhibit other signs of deterioration or when their ability to function as a barrier is compromised.

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4. It is not necessary to wear gloves when patient contact is not anticipated unless any activity being undertaken will result in contact with a contaminated or potentially contaminated surface

5. Gloves should be changed between each patient contact.6. Clinical staff should wear two pairs of surgical gloves, one over the other, during surgical

and other invasive procedures with the potential for exposure to blood or other potentially infectious material. When double gloves are worn perforation indictor systems (base glove being a different color than cover glove) should be used.

7. Thorough hand hygiene should occur: Between patient contacts If contaminated with blood or other infectious materials Prior to donning gloves Following glove removal Prior to eating After using toilet facilities After covering the nose and mouth when coughing or sneezing After trash and/or infectious waste disposal Anytime hands are visibly soiled

Masks in combination with eye protection devices, such as goggles or glasses with solid side shields, or chin-length face shields, will be worn whenever splashes, spray, spatter, or droplets of blood or other potentially infectious materials may be generated and eye, nose, or mouth contamination can be reasonably anticipated. The type of eye protection that is necessary depends on the circumstances of the exposure, other PPE being used, and personal vision needs. However, regular prescription eyeglasses and contact lenses are not considered eye protection. If wearing goggles they should fit snugly, especially at the corners of the eye and across the brow, be indirectly vented, and have anti-fog properties. Face shields should be selected when eye protection alone is not sufficient. When masks, protective eyewear, and face shields are removed they will promptly be placed in the appropriately designated area or container for storage, washing, decontamination or disposal.

Appropriate protective clothing such as, but not limited to: gowns, aprons, lab coats, clinic jackets, or similar outer garments will be worn in occupational exposure situations. The type and characteristics of the protective clothing worn will depend upon the task and degree of exposure anticipated. When removed the protective clothing should be promptly placed in the appropriately designated area or container for storage, washing, decontamination, or disposal.

Sharps injury protection devices will be reviewed at least annually, new devices will be trialed and decision to utilize said devices will occur after input is received from non-managerial employees responsible for direct patient care. Types of devices include but are not limited to: needleless systems when withdrawing body fluids; use of round tipped scalpel blades instead of sharp tipped blades; use of retractable, self- sheathing, or self- blunting angio-catheters and use of retractable, self-sheathing or self-blunting needles to administer injectable medications.

All personnel will follow the sharps injury protection guidelines as outlined in the Sharps Injury Prevention Program, which is located in the Exposure Control Plan.

PRECAUTIONS FOR INVASIVE PROCEDURES

12

An invasive procedure is defined as surgical entry into tissues, cavities, organs, or repair of traumatic injuries in the following settings or situations: operating rooms, endoscopy rooms, or treatment rooms.

In addition to the previously listed barrier precautions, healthcare workers performing or assisting in invasive procedures should follow these additional guidelines:

1. Extraordinary care should be taken to prevent hand injuries caused by needles, scalpels, and other sharp instruments or devices utilized during invasive procedures; when cleaning used instruments; during disposal of used needles; and when handling sharp instruments after a procedure.

2. Sharps with engineered injury protection mechanisms, safety features and/or needleless systems should be used for withdrawing body fluids, accessing a vein or artery, administering medications or other fluids, or other procedures involving the potential for blood borne pathogen exposure due to percutaneous sharps injuries. Blood-tube holders with engineered sharps protection will be single-use only, with disposal upon activation of safety feature as a single unit after each blood draw.

3. Contaminated needles and sharps will not be recapped or removed unless no other alternative is feasible or such action is required by a specific medical procedure. Recapping or needle removal must be accomplished through the use of a mechanical device or a one-handed technique. Shearing or breaking off of contaminated needles is strictly prohibited.

4. If a glove is torn or a needle-stick or other injury occurs, the glove should be changed as soon as possible (hands should be washed) and the needle or instrument(s) removed from the sterile field.

5. Gloves and surgical masks must be worn for all invasive procedures.6. Protective eyewear or face shields will be worn for procedures that commonly result in the

generation of droplets, splashing of blood or other body fluids, or the generation of bone chips. Procedures will be performed in such a manner as to minimize splashing, spraying, spattering, and generation of droplets of these substances.

7. Gowns or aprons for use during the performance of invasive procedures will be made of materials providing an effective barrier between the employee and potential contaminants.

Proper technique will be maintained during the preparatory, performance, and clean-up phases of any invasive procedure. This requires that:

1. All patients will be considered potentially infectious. Protective measures and body fluid containment will be instituted per policy for all patients.

2. All trash will be appropriately contained and taken to the soiled utility area for proper disposal.

3. All linen will be placed in leak-proof bags, placed in the soiled utility area, and sent for proper laundering.

4. All contaminated needles and sharps will be placed in biohazard containers. Once full, the containers will be sealed closed and taken to the soiled utility area for proper disposal.

5. All contaminated or potentially contaminated equipment will be wiped down thoroughly with a germicidal solution.

EQUIPMENT SHOULD BE ALLOWED TO AIR DRY! Soiled instruments will be manually rinsed in cold water and taken to the decontamination

area

13

Delicate instruments that cannot withstand high temperatures or vigorous washing will be soaked in a germicidal solution for 45 minutes or per manufacturer’s instructions

Protective apparel will be worn when handling soiled articles, instruments, or patient’s body fluids. A face shield, non-sterile gloves and protective apron will be worn throughout the decontamination process.

All personnel will follow the appropriate hand hygiene practices

14

OSHA COMPLIANCE ANNUAL CHECKLISTGeneral Safety Yes No N/A Comments

“It’s the Law” OSHA poster current and visible to all employeesOSHA Compliance Manual current and easily accessibleThe practice is maintained in a clean, sanitary conditionAppropriate signage is used to designate restricted areas of the practicePractice maintains and posts an up-to-date emergency contact listAll supplies are at least 18 inches from the ceiling in a sprinkler buildingAll employees undergo annual OSHA training on bloodborne pathogens, use of PPE, hazard communication, and TBOSHA training records for the last 3 years are availableAnnual TB risk assessment is completed on all employeesTB skin test records are on file for all employeesEmergency Exit Routes Yes No N/A Comments

Exit routes are unobstructed by materials, equipment, or locked doorsLighting for exit routes is adequate for employees EXIT signs are illuminated and back up lights/batteries are functioningEXIT signs are in plainly legible lettersThe line of sight to an exit sign is clearly visible at all timesA diagram of the exit route(s) is posted in a central and easily accessible locationElectrical Hazards Identification Yes No N/A Comments

Outlets are not overloaded with too many plugsOutlets are in good working conditionAll switches and outlets work appropriately Medical equipment cords have grounded 3-prong plugsElectrical cords are in good working conditionNo frays, defects, etc.Electrical cords are managed to prevent tripping hazardsElectrical equipment/appliances used in areas that may get wet are properly groundedAll junction boxes, outlets, switches, and fittings are properly covered.

Fire Safety Yes No N/A Comments

The fire alarm is in proper working condition

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An appropriate number of fire extinguishers is present and accessibleFire extinguishers have been inspected and tagged within the last 12 months, and are fully chargedAll employees have been trained on how to respond should a practice fire occur (R.A.C.E)Eye wash stations Yes No N/A Comments

Eye wash stations are easily identifiable and unobstructedAll eyewash stations are in good working orderEyewash station weekly check log is in place and up to dateBloodborne Pathogens Standard Yes No N/A Comments

Practice maintains an accident/sharps injury logPractice can show evidence of consideration for sharps safety devicesHepatitis B vaccination records are available for all employeesSharps containers are in proper locations and positioned firmly so they cannot be knocked overSharps containers are replaced as soon as they reach the fill linePPE is in the proper locations and available in the correct size and amounts and functions properlyContaminated items and regulated waste are placed into appropriate biohazard bags and containers that display the biohazard symbolPractice has a blood spill policy Blood spill kit is easily accessible to employeesHazard Communication Yes No N/A Comments

MSDS/SDS binders are easily accessible to all employeesThe Hazardous Substances List contains all hazardous chemicals in the practiceHazardous chemicals are stored properly and are disposed of properlyChemicals are labeled legibly with hazards and dangers clearly labeled. Labels match the identity on the corresponding MSDS/SDS

16

DEVICE TRIALED INSTITUTEDNOT

INSTITUTED COMMENTS

17

SHARPS SAFETY DEVICES TRIALED YEAR____________

SHARPS DEVICE EVALUATION FORM

PRODUCT: ________________________________________________ DATE:___________________

DEPARTMENT ________________________________ POSITION/TITLE: ______________________

NUMBER OF TIMES YOU USED THIS DEVICE: 1-5 6-10 11-15 16-20 More than 20

Patient/procedure considerations TRUE FALSE COMMENTSNeedle penetration is comparable to the standard deviceUse of the device does not increase the amount of needlesticks to the patientUse of the device does not change the procedural techniqueUse of the device does not increase the time that it takes to perform the procedureThe device is compatible with existing equipmentUse of the safety device is not affected by hand sizeSafety device is user friendly

Use of Safety Feature on the Sharps DeviceThe safety feature is easy to activate

The safety feature does not interfere with the procedural techniqueThe safety feature does not activate prematurelyOnce activated the safety feature remains activatedI did not experience any sharps injury or near miss while using the device

On a scale of 1-10 (10 being the highest), how would you rate this product? _________________

Do you feel this device provides sharps safety to the staff? ______________________________

Additional Comments: __________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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SHARPS SAFETY SURVEY CHECKLIST

Instruction: use this sheet as a prompter. A “no” response indicates a potential sharps injury factor.Policies and procedures Yes No CommentsAre Sharps injury Prevention policies and procedures in place?Is incident reporting and investigation in place?

Is management supportive and involved in sharps injury prevention devices?Consultation ProcessIs selection of work practices utilized at practice made with input from non-managerial employees responsible for direct patient care?Is selection of sharps injury prevention devices utilized at practice made with input from non-managerial employees responsible for direct patient careEducation and TrainingIs sharps injury prevention training made available to all staff?Is sharps injury prevention training completed with the orientation process of new employees?Is training performed with the introduction of any new sharps injury prevention device?Is sharps injury prevention occurring on an annual basis?Is the Sharps Injury Log utilized?Work Practice ControlsIs adequate lighting and space available to staff when using sharps devices?Is staff utilizing the concept of the “neutral zone” when passing sharps?Is staff utilizing the disposable, puncture resistant container provided to them to contain their reusable sharps throughout the procedure?Is staff activating the safety feature on their sharps devices immediately after the procedure is completed?Are staff double gloving?Is staff transporting reusable sharps in a closed container?Is staff keeping hands behind the sharps at all times when disposing of sharps?Engineering ControlsAre sharps containers readily identifiable with a biohazard symbol and color coded (red, red- orange, orange)Are sharps containers located close to the point of use and in every patient area?

19

INFORMED CONSENT FOR HEPATITIS B VACCINE

I, _______________________________________________________________________

hereby authorize my employer to vaccinate me against the Hepatitis B virus (HBV). I understand that to receive full vaccination that a series of three injections is given over a period of six months before it is effective in preventing Hepatitis B.

I have been informed of the potential side effects that may result from the HBV vaccines. These side effects include but are not limited to:

Itching Pain at the injections site Weakness Chills Flushing Tingling Bruising at the injection site; and/or Other side effects (review the most recent The Physicians’ Desk Reference and manufacturer’s

information sheets for current listings of the vaccine side effects).

I have been informed that there are contraindications to receiving the Hepatitis B vaccine, including:

Hypersensitivity to the drug Hypersensitivity to gamma globulin’ Hypersensitivity to yeast Cautioned administration to nursing mothers

Additional warnings and contraindications are also noted in the reference guides mentioned above.

I have had the opportunity to ask questions and have had them answered to my satisfaction. I state that it is my belief that I understand and have been given adequate knowledge upon which to base my informed consent to receive the Hepatitis B vaccination. I hereby acknowledge that no guarantees have been made to me concerning the results or level of immunity from the proposed vaccination. I hereby release my employer from any and all liabilities and legal responsibilities of my decision to receive the vaccination.

Signature:______________________________________________________________Date:__________

Safety Officer’s Notation:

This employee has agreed to receive vaccination against the Hepatitis B virus. The vaccination series of three injections will be provided at no cost to the employee by this practice.

Safety Officer Signature: __________________________________________________ Date: _________

Note: Maintain this record for the duration of employment plus 30 years.

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INFORMED REFUSAL FOR HEPATITIS B VACCINE

Based on the risk of occupational exposure to blood and other potentially infectious materials related to my job position at the practice, I __________________________________________,have been given information and training about Hepatitis B and understand my risk of acquiring the Hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with the Hepatitis B vaccine at no charge to myself. However, I decline Hepatitis B vaccine administration at this time. I understand that by declining this vaccine, I will continue to be at risk for exposure and infection with Hepatitis B.

If in the future, I am employed at Green Hills Direct Family Care in a job position that has the risk of occupational exposure to blood or other potentially infectious material, I may decide I want to be vaccinated with the Hepatitis B vaccine and can request and receive the vaccination series at any time and at no charge to me.

Employee Signature:_____________________________________________________________

Employee Name:(Print Legibly)__________________________________________________________________

Employee Address: _____________________________________________________________Street Address

______________________________________________________________City State zip code

Date: ___________/__________/_________

Witness Signature:______________________________________________________________

Date: ____________/________/___________

Note: Maintain this record for the duration of employment plus 30 years.

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OCCUPATIONAL EXPOSURE INJURY/INCIDENT REPORT

Name/Title of Injured/exposed employee:____________________________________________

Date of Injury:________/______/______ Date Injury Reported____/____/____

Time of Injury: ____________________ Time Injury Reported_____________

If an individual injured is not an employee at the practice, please indicate employer name, address, and phone number:

Name:________________________________________________________________________

Address:_______________________________________________ Phone:_________________

Employer:_____________________________________________________________________

Facts of Exposure/Incident/Injury

Describe the activity being performed by the employee when the exposure or injury occurred. (Be specific. Identify if the employee was utilizing equipment or instrumentation or handling material at the time of exposure).________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Explain how the incident occurred. List any event(s) that may have or did lead to and result in the exposure or injury.________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Describe the nature of the injury. (i.e., needlestick/sharps exposure, etc.) Be specific in identifying the body part(s) injured.________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Describe any actions that could be taken to prevent or minimize this type of incident.______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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FOLLOW-UP TO EXPOSURE/INJURY/INCIDENT REPORT

MEDICAL TREAMENT

First Aid rendered:____________ Area washed with soap and water____________ Sterile dressing applied____________ Suture necessary- Type____________ Sutured by:____________

Other: (Be Specific)__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

INITIAL COUNSELING FOR HIV/HBV EXPOSURE

REFERRED (for further HIV/HBV exposure counseling and opinion re: degree of exposure)[ ] To Company Physician:____________________________________________________[ ] To Family Physician: __________________________ Phone #:____________________

Appointment Date: _____/_____/____ Appointment time:____:____ AM/PM[ ] Emergency Facility:_______________________________________________________

If HIV/HBV Exposure:

Opinion Received [ ] YES [ ] NOFollow-up completed based on written opinion [ ] YES [ ] NOOpinion and follow-up filed with appropriate individual [ ] YES [ ] NO

Did individual receive HBV booster (if applicable)? [ ] YES [ ] NODid individual involved receive follow-up lab work? [ ] YES [ ] NO

(If yes, please check applicable timeframes that blood work was completed):

___ 1 month ___ 12 weeks ___ 6 months ___ 1 year

________________________________________ ____/____/____Signature of Individual completing Follow-up form Completion Date

23

JOB RISK DETERMINATION FORM

This form is used to determine your potential exposure levels to bloodborne pathogens

Name:______________________________________ Date:____/____/____

Job Title:_____________________________________

Categories of worker’s at risk: Examples are:

High Exposure Risk Physicians, dentists, nurses, and all persons potentiallyExposed to pathogens on a regular (daily) basis.

Medium Exposure Risk Housekeeping and x-ray where occasional potential Exposure once a week or more may occur.

Low Exposure Risk Receptionist and business office employees with nousual contact with exposed blood or body fluids.

Please review the following tasks and procedures. Check the tasks that you perform. Write in other tasks which are not noted here but which might expose you to blood or other potentially infectious pathogens. Assume that you do not have protective equipment available to you for these tasks.

[ ] phlebotomy[ ] procedures involving body orifices, such as pelvic exams and sigmoidoscopies[ ] perform or assist in a surgical procedure (ex: suturing)[ ] cleansing and or dressing an open wound[ ] contact with body fluids such as saliva, urine, feces[ ] X-ray(s) of open wounds[ ] cleansing and/or sterilization of instrumentation[ ] housekeeping tasks- toilets, floors, emptying of infectious wastes such as blood or urine soaked

linens[ ] other task of potential exposure not listed: ___________________________________________

______________________________________________________________________________

Safety Officer’s determination of exposure risk (check one)

Low Risk:_____ Intermediate Risk:_____ High Risk:_____[ ] This employee does require bloodborne pathogen protection. The employee has access to

personal protective equipment at this Practice, has been offered the HBV vaccine, and has been instructed about bloodborne pathogens; including methods to minimize or eliminate risk of exposure.

[ ] This employee does NOT require bloodborne pathogen protection.

Date:____/____/____ Safety Officer:_________________________________

Reviewed on:____/____/____Reviewed on:____/____/____Reviewed on:____/____/____

24

Note: Maintain this record for review annually

25

EXPLANATION OF AND CONSENT OR DECLINE FOR HUMAN IMMUNODEFICIENCY VIRUS (HIV) AND HEPATITIS B VIRUS TESTING OF

SOURCE INDIVIDUAL FOLLOWING EMPLOYEE EXPOSURE

EXPLANATION

A member of our Practice staff was accidentally exposed to your blood or body fluid. In order to comply with recommendations of the Centers for Disease Control and Needlestick/Sharps Instrument Accident protocol, we are requesting your consent to test your blood for the antibody to the human immunodeficiency virus (HIV) and the Hepatitis B virus (HBV). This test will show whether or not you have been exposed to HIV or HBV. It will not show whether or not you actually have AIDS or Hepatitis B (or an AIDS/HBV related illness).

Your consent will enable our practice to provide necessary care and assist in the proper medical management of the exposed employee. It is important that you understand the following:

1. We cannot test you for HIV or HBV without your consent.2. You will not be charged for the blood draw, testing or interpretation/reading of the test

results.3. The signed consent and the test results will be kept confidential and will NOT be placed

in your medical records.

The test results will be reported to the physician counseling the Practice employee.

CONSENT/DECLINE

I have been informed about the implications and limitations of the test for the antibody HIV and HBV. I have been able to ask questions about the test and my questions have been answered to my satisfaction. I understand the benefits and risks of the HIV/HBV test.

[ ] I hereby consent to have my blood [ ] I hereby decline to have my blood Tested for HIV/HBV antibody tested for the HIV/HBV antibody

[ ] I would like to know the results of the HIV/HBV antibody test. I understand that I will be notified by the physician counseling the practice employee.

_____________________________________ ____/____/____Patient signature date

________________________________________ ____/____/_____If patient unable to consent, authorized signature date

________________________________________ ____/____/____Relationship to patient date

________________________________________ ____/____/____Witness signature/ Title date

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PHYSICIANS/INFORMANT’S CERTIFICATION

I certify that I have personally explained the above consent form to the patient or guardian of the patient, if the patient is unable to understand and complete the form. My explanation has included: a) the reasons for conducting the test, b) the type of test, c) the risks and the alternatives to the test, if any, d) the uses, limitations and meanings of the test results and e) the effect the test results may have on the patient’s medical regimen.

If the patient has requested additional information before the execution of the form, I have provided the patient with such information. I have informed the patient that post-test information and face to face counseling is available in the event of a confirmed positive result. I or an appointee designated by me, or a successor physician standing in the same relationship to the patient as myself, will undertake the responsibility of notifying the patient of the test results and providing post- test counseling as provided by ACT 148 of 1990 known as the “Confidentiality of HIV-Related Information Act”.

Date:____/_____/_____ Time:_____:_____ AM / PM

________________________________________________________________________Physician/Informant Signature/Title

_________________________________________________________________________Witness Signature/Title

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EMPLOYEE HEALTH HISTORYEmployee Name:__________________________Address:_________________________________________________________________________________________________________________

In case of emergency notify: _________________Phone#:

Date: _____/_____/_____

DOB: _____/_____/_____

Home Phone: Family Physician:__________________________Phone #:

Do you or any of your family have the following conditions?Indicate relationship to self:

Disease State Yes No RelationshipAsthma ______________________________Cancer ______________________________Diabetes ______________________________Elevated Cholesterol ______________________________Heart Disease ______________________________Hypertension ______________________________Immunologic Disease ______________________________Lung Disease ______________________________Neurological Disease ______________________________TB (or exposure to TB) ______________________________

Have you ever received the Hepatitis B vaccine? [ ] yes [ ] NoIf yes, when did you have the injections (please provide proof of injections received)1st dose_______________ 2nd dose __________________ 3rd dose _______________________Where did you receive the injections? ______________________________________________If no do you wish to receive the Hepatitis B vaccine at this time? [ ] yes [ ] NoHave you ever received a TB test in the last 12 months? [ ] yes [ ] NoIf yes please provide results [ ] negative [ ] positiveIf positive, have you received treatment for the positive result? [ ] yes [ ] NoPlease list all medications that you are currently using:Name of Medication Dosage Frequency of Administration________________________ _________ _______________________________________________________ _________ _______________________________________________________ _________ _______________________________________________________ _________ _______________________________

Have you ever received a blood transfusion? [ ] yes [ ] NoIf yes list date of transfusion(s) _____/____/_____, _____/_____/_____Do you have any current conditions that would prohibit you from performing your job responsibilities?________________________________________________________________________________________________________________________________________________________________________

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EMPLOYEE INFORMED REFUSAL OF POST EXPOSURE MEDICAL EVALUATION

I, ____________________________________________________, as an employee of (First, Middle, Last Name, Title)

Green Hills Direct Family Care, have been provided with training in bloodborne pathogen policies, procedures, and risk of pathogen transmission.

On________________________, _____________________, 20______, I was involved in an (Day of week) (Month and Date)

exposure accident when (describe the accident/injury):____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Equipment Involved: ________________________________________________________________________________________________________________________________________________________________________________________________________________________

Due to this exposure incident, my employer has offered to provide me with post-exposure medical evaluation to assure that I have full knowledge of my degree of exposure and whether I have contracted an infectious disease from tis exposure incident.

After receiving my employer’s offer for post-exposure medical evaluation, I have elected of my own free will and volition, not to have post exposure medical evaluation. I have made this decision based on my own personal reasons.

Employee Signature: ___________________________________________________________

Name (please print): _____________________________________________________________First Middle Last

Address: ______________________________________________________________________Street Address

_____________________________________________________________________________________City State Zip Code

Date of Signature: ____/____/_____

Witness Signature/Title: __________________________________________________________

Note: Maintain this record for the duration of employment plus 30 years.29

SUMMARY LOG OF OCCUPATIONAL PERCUTANEOUS SHARPS INJURIESGREEN HILLS DIRECT FAMIY CARE YEAR________

CASE #

DATE OF PERCUTANEOUS SHARPS INJURY EXPOSURE

EMPLOYEE OCCUPATION/POSITION

SITE/DEPT OF EXPOSURE

TYPE AND BRAND OFDEVICE INVOLVED IN THE INCIDENT

DESCRIPTION OF SHARPS INJURY OCCURANCE

File in OSHA Reports File - Maintain for 5 Years

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WORK RELATED SHARPS INJURY STATISTICSTYPE AND NUMBER OF SHARPS INJURIES

Type Number Total days of restricted

work activity per

type of sharps injury

Average days of

restricted work

activity per type of

sharps injury

Total days away from work per

types of sharps injury

Average days away from work per type of

sharps injury

Injuries without lost days per type of sharps

injury

Average injuries without lost days per type of sharps

injury

IV stylet

Phlebotomy Needle

Hollow Bore needle

Winged Steel NeedleHypodermic

NeedleSuture NeedleGlass

Other Sharps

Aggregate Number of

Sharps Injuries

N/A N/A N/A

31

File in OSHA Reports File - Maintain for 5 years

32

BLOODBORNE PATHOGENS STANDARD PRE-TEST

Name:_________________________________________ Date:___/___/___

Job Title:_______________________________________ Number Correct: ___/10

Instructions: Read each Statement. Circle the appropriate response (“T” if statement is true; “F” if statement is false)

1. Work practices such as recapping of used needles, eating, drinking in patient T FCare areas and storing food in medication or specimen refrigerators is acceptable as long as it is approved by employee supervisor.

2. HIV is more easily spread from person to person in a healthcare practice than T FHBV.

3. Standard or Universal Precautions are not required to be used for all patients T Funless the patient is suspected of having an infectious process.

4. Employees must use the personal protective equipment provided by their T Femployer and are responsible for their own cleaning, laundering, and maintenanceof the equipment used.

5. Thorough handwashing is the most effective method of preventing the spread of T Finfection.

6. All containers with potentially infectious material should be color-coded or labeled T Fwith the biohazard symbol.

7. The Hepatitis B vaccine is a single injection that must be received every 5 years T Fby each employee.

8. Any exposure incidents must be reported immediately to the employee’s T Fsupervisor for appropriate action.

9. All employees must receive appropriate training annually on Bloodborne T FPathogen exposure control.

10. An employer is not required to keep a separate, confidential record for an T FEmployee who has experienced an occupational exposure if they have receivedOSHA’s annual occupational illness and injuries form.

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BLOODBORNE PATHOGENS STANDARD POST-TEST

Name:___________________________________________ Date:____/____/____

Job Title: ________________________________________ Number correct: ____/15

Instructions: Read each statement. Circle the appropriate response.

1. More health care workers contract hepatitis than AIDS.A. TrueB. False

2. Hepatitis A is the most common chronic bloodborne infection currently in the U.S.A. TrueB. False

3. Hepatitis A & E are spread through oral and fecal routes instead of through contact with blood. A. TrueB. False

4. A bloodborne pathogen:A. Is found routinely in blood onlyB. Does not cause disease or infectionC. Can be present in blood and other body fluidsD. Does not need to be treated

5. The hepatitis B vaccine series consists of 3 injections delivered initially, at one month, and at 6 months to achieve immunization against the hepatitis B virus. A. TrueB. False

6. Personal protective equipment must be worn any time a health care worker anticipates exposure to a patient’s blood or body fluids. A. TrueB. False

7. A large majority of exposures to bloodborne pathogens:A. Occur on an everyday basisB. Are due to poor hygiene in the workplaceC. Are caused by accidents during use of disposable syringesD. Do not require being reported to the employer

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8. The HIV virus can:A. Be spread through contact with body fluidsB. Not be transmitted from mother to infantC. Survive outside of the body indefinitelyD. Be cured with medication

9. Tuberculosis (TB) is spread through:A. Hand to hand contactB. Direct inhalation of expelled breath/cough/mucous spray from an infected individualC. An infected needlestickD. Contact with urine and feces

10. Hepatitis B is all of the following except:A. A disease of the liverB. Able to survive outside of the body for up to seven (7) daysC. Evidenced by classic symptoms such as jaundice, fatigue, and dark colored urineD. A temporary illness that cannot be immunized against

11. Standard/Universal Precautions require that health care workers must take special precautions only with patients who are infected with hepatitis or HIV.A. TrueB. False

12. Which of the following is the most common chronic bloodborne infection in the U.S.?A. Hepatitis CB. Hepatitis BC. HIVD. Tuberculosis

13. Personal protective equipment (PPE) is provided by your employer:A. To use in reducing direct exposure to blood and body fluidsB. For your individual use at the workplace and at homeC. To use at your discretion when involved in an exposure situationD. In only one size, without regard to varying needs of the employees

14. The risk of contamination from blood and/or body fluids can be reduced by all of the following except:A. Thorough handwashingB. Use of personal protective equipmentC. Recapping used needlesD. Use of gloves for handling of any bloody or potentially contaminated items

15. An individual infected with tuberculosis (TB):A. Can be treated with INHB. May exhibit signs and symptoms of persistent cough, fever and night sweats

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C. Can be diagnosed with a combination of a PPD test, CXR, and sputum sampleD. All of the above

BLOODBORNE PATHOGENS PRE AND POST-TEST ANSWER KEY

PRE-TRAINING PROGRAM TEST ANSWERS:

1. F2. F3. F4. F5. T6. T7. F8. T9. T10. F

POST-TRAINING PROGRAM TEST ANSWERS:

1. A2 B3. A4. C5. A6. A7. C8. A9. B10. D11. B12. A13. A14. C15. D

36

HAZARD COMMUNICATION PLAN

Hazard Communication is defined as the classification of the potential hazards of chemicals and the communication of that information concerning the potential hazards to the employees that come in contact with the chemical. Hazard communication also addresses the use of appropriate protective measures for the employee using the hazardous chemical. The purpose of the Hazard Communication Plan and Policy is to educate physicians and staff regarding the hazardous chemicals which they may come in contact with on a routine basis, educate staff on the safe handling of the hazardous materials and give them steps to take to ensure protection from harm. Healthcare facilities must follow the most stringent federal, state or local regulations for handling and disposing of chemicals. State and local requirements may be more stringent than federal regulations. Green Hills Direct Family Care will follow the most stringent of the regulations.

As of 2013 OSHA has aligned with the Globally Harmonized System (GHS) of Classification and Labeling of Chemicals. This new system calls for a standardized approach by manufacturers and importers when classifying and labeling Safety Data sheets. Prior to adoption of the GHS, manufacturers and importers were able to pass on chemical hazard information in whatever format they chose. The revised standard requires that information about chemical hazards be conveyed on labels using quick visual pictograms to alert the user thereby providing immediate recognition of the hazards. Labels must also provide instruction on how to handle the chemicals. Use of the GHS will ensure a standardized approach to the labeling requirements.

They have changed the title of the MSDS (Material Safety Data Sheet) to SDS (Safety Data Sheet). With the adoption of the GHS, manufacturers and importers will be required to use a 16 section safety data sheet format, providing detailed information regarding the chemical. The updated requirements now align with international requirements. The three major changes are in:

Hazard classification - To provide specific criteria for classification of health and physical hazards as well as classification of mixtures,

Labels - Manufacturers and importers will be required to provide a label that includes:o a harmonized signal word, there are only 2 signal words- “Danger” and

“Warning”o Pictogram-must be in the shape of a square set at a point and include a black

hazard symbol on a white background with a red frame sufficiently wide enough to be clearly visible. OSHA has designated eight pictograms for application.

o Hazard statement- describes the nature of the hazard of the chemical and where appropriate, the degree of hazard

o Precautionary Statement-recommended measures that should be taken to minimize or prevent adverse events form exposure.

o Name, address, and phone number of the chemical manufacturer, distributor, or importer

Safety data sheets(SDS) - will now follow a specified 16 section format

A pictogram form is referenced at the end of this chapter.

Green Hills Direct Family Care will follow the new Standard.

This manual shall be available at the worksite for the employee to access and reference. A copy may be requested by the employee and provided by the employer within 15 days of the request.

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An employee covered by this Hazard Communication Plan is defined as any full-time, part-time, temporary, contract, or per diem employee.

PROGRAM ADMINISTRATION

Green Hills Direct Family Care is responsible for the implementation of an active Hazard Communications program. It will maintain, review, and update the Hazard Communication plan at least annually and whenever necessary to include any modifications to the plan or additions of chemicals to the practice. It is the responsibility of the practice’s Safety Officer to ensure compliance with OSHA Hazard Communication Standard, Title 29, and Federal Regulations Code 1910.1200

When a new employee is hired or an existing employee changes jobs or assumes other tasks not previously performed, the following process will take place to ensure that they have been trained in the appropriate work practice controls:

The employee’s job classification and the tasks and procedures that they will perform are evaluated in order to identify specific hazards relevant to the position.

Proper training will take place regarding the Hazard Communication Standard and the safe use and administration of hazardous chemicals present in the practice.

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HAZARD COMMUNICATION POLICY

POLICY

It is our policy to assess the chemical hazards to which an employee may potentially or actually be exposed to in the course of a normal workday in the workplace. For the purposes of this policy, employee shall be defined as any full-time, part-time, per diem, or temporary employee.

The intent of the hazard communication policy is to educate Green Hills Direct Family Care’s employees about the:

hazardous nature of the chemical substance(s) which they may come in contact with during the routine course of the workday

physical hazards which they may come in contact with during the routine course of the workday

procedures for proper and safe handling of the hazardous materials steps to take to protect oneself from harm.

PURPOSE

It is the responsibility of the Safety Officer to comply with OSHA Hazard Communication Standard, Title 29, and Federal Regulations Code 1910.1200.

The employer is required to provide full support and authority to ensure compliance with this OSHA standard is maintained.

STANDARD REQUIREMENTS

To facilitate a safe and healthy workplace, the safety officer will:

1. Establish a workplace program for hazard communication2. Prepare a current listing of hazardous chemical substances present in the workplace3. Compile a library of Safety Data Sheets (SDS) (formerly known as MSDS sheets)4. Establish workplace safety practices5. Ensure all containers are properly labeled6. Educate employees on how to evaluate container labels for hazard and other warnings7. Educate each employee on how to use MSDS and apply their contents in the workplace

The program is intended to instruct employees on:

1. The Hazard Communications Standard2. The hazardous properties to chemicals to which they could be exposed3. Safe handling procedures4. Safety measures that can be taken to protect them from hazardous chemicals

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PREPARATION OF THE LISTING OF HAZARDOUS CHEMICALSUBSTANCES – (see related form)

Identify Hazards:

1. Check label on the product for warnings and/or precautions2. Identify any medications or chemicals that may cause toxic effects to an employee when

handling such as: Genotoxicity Carcinogenicity Teratogenicity Serious organ or other toxic manifestations at low doses in experimental animals or

treated patients

The Listing for Hazardous Chemical Substances shall include:

1. An inventory of every chemical and brand name of each product present in the workplace2. Notation of the physical location of the product in the practice3. The name and address of the chemical’s manufacturer4. The manufacturer’s intended use of the product5. List of the hazards of the product and which organs it targets6. List of any personal protective equipment that should be worn throughout handling and use

of the product

NOTE: Warnings like “Flammable,” “Requires well-ventilated area,” “Do not heat beyond 120 degrees,” etc. are the types that should alert personnel to list the particular product as a hazardous chemical substance in the workplace.

HAZARD DETERMINATION AND SAFETY DATA SHEETS (SDS )

Order appropriate SDS

1. Each SDS shall be in English and contain at least the following information:. Section 1. Identity used on the label (i.e., chemical and/or common name or ingredients) Section 2. Hazard Identification Section 3. Composition/Information on ingredients Section 4. First Aid measures Section 5. Fire Fighting Measures Section 6. Accidental Release Measures Section 7. Handling and Storage Section 8. Exposure Controls/personal protection Section 9. Physical and Chemical Properties Section 10. Stability and Reactivity Section 11. Toxicological Information Section 12. Ecological Information Section 13. Disposal Considerations Section 14. Transport Information Section 15. Regulatory Information Section 16. Other Information, including date of preparation or last revision

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All information on the SDS shall be presented using specific headings in a specified sequence2. If there is any doubt whether an MSDS/SDS is required for a product, one will be purchased

and included in the SDS file.3. All MSDS/SDS will be obtained from the manufacturer responsible for producing the

MSDS.4. An MSDS/SDS will be obtained for each individual product.5. If there is a conflict between the container label and the SDS, the SDS shall prevail.

Arrange MSDS/SDS in accessible file

1. Prepare an alphabetical file, by brand name, in a binder with an MSDS for every hazardous product present in the practice.

2. Place copies of each MSDS/SDS in accessible areas of the practice, especially departments or areas where the specific chemicals may be utilized or stored.

3. MSDS/SDS sheets must be readily accessible during each work shift to employees in the work area.

LABELING

All materials not in their original container, whether hazardous or not, will be labeled accordingly.

The Safety Officer will supervise labeling of in-house containers.

All existing labels on incoming containers of hazardous chemicals shall not be removed or defaced unless the contents are immediately marked with the required information.

The Safety Officer or designee will update the Listing of Hazardous Chemical Substances to include new items and ensure that related SDSs are within the practice before releasing the product for use.

Any new or significant information regarding the hazards of a chemical currently being used within Green Hills Direct Family Care shall be shared with employees within 3 months of the employer becoming aware of the new information. Labels on these specific hazardous materials will be revised immediately and appropriately.

Labels of chemicals not in their original container will be legible, prominently displayed, in English, and include the following information:

1. Brand name of the material2. Chemical identity of the material(s) in the product3. Name, address, and phone number of the manufacturer, importer, or other responsible

party4. Physical and chemical hazard(s) associated with the material5. Target organ(s) affected by the chemical(s) in the material

Labeling is not required for temporary individual-use containers

Exempt items:

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1. Tablets, pills and capsules which are ready for direct administration2. Medications packaged by the manufacturer for sale to consumers (e.g. over-the-counter

drugs)3. Medications intended for personal consumption by employees (e.g. aspirin or first aid

items)

Non-exempt items:

1. Powders, aerosols or liquid prescription drugs2. Antineoplastic agents

Containers of hazardous chemicals leaving the workplace must be labeled, tagged, or marked in accordance with this policy and OSHA standard 29 CFR 1910.1200 in such a manner that it does not conflict the requirements of the Hazardous Materials Transportation Act (49 U.S. C. 1801 et seq.) and regulations issued under the Act by the Department of Transportation.

EYE WASH STATIONS

An emergency eye wash station must be immediately available to employees who work in an area where chemical substances which are hazardous to the eyes are present. Each eye wash station should be fully operational, accessible in the immediate area to where hazardous chemicals are present, and be present in a location that requires no more than 10 seconds to reach from the location where the hazardous chemical is used. Bottled Eyewash Units are considered to be supplemental equipment only. These types of flushing units do not meet ANSI's requirements for Eyewash stations and should not be used as an alternative to a 15 minute flushing station. The ANSI Z358.1-2009 standard states, "A personal wash unit may be kept in the immediate vicinity of employees working in a potentially hazardous area. The main purpose of these units is to supply immediate flushing. With this accomplished, the injured individual should then proceed to a plumbed or self-contained Eyewash and flush the eyes for the required 15-minute period."

PERSONAL PROTECTIVE EQUIPMENT

Personal protective equipment will be provided whenever exposure to hazardous physical, chemical, and/or biological agents can cause injury or other impairments through inhalation, absorption or other physical contact.

Personal Protective Equipment includes:

1. Protective equipment and protective clothing2. Respiratory devices3. Protective shields and barriers

Eye and Face Protection:

1. Goggles, shielded glasses, masks and/or face shield will be worn when there is a possibility of injury from flying particles, molten metal, liquid chemicals, acids or caustic liquids, chemical gases or vapors, and/or potentially injurious light radiation.

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2. Masks in combination with eye protection devices, such as goggles or glasses with solid side shields or chin-length face shields, will be worn whenever splashes, spray, splatter, droplets of hazardous chemicals or materials may be generated and may be reasonably anticipated to result in injury to the eye, nose or mouth.

3. Eye protection equipment will be designed to provide adequate protection against the particular hazard(s) to which the employee is or may be exposed.

4. Employees wearing glasses for vision correction may comply with OSHA requirements by wearing any of the following: Goggles that fit over corrective glasses without disturbing them Safety glasses that have the optical correction incorporated in the protective lenses Goggles that have a pair of corrective lenses mounted behind the protective lens

Hand Protection:

1. Gloves will be worn routinely to protect against exposure to hazardous chemicals2. See Exposure Control Plan for specific information regarding hand protection

FORMALIN HANDLING REQUIREMENTS

Formaldehyde, the active ingredient in Formalin, is a known carcinogen and may cause other acute and chronic health conditions. Safe handling practices will be followed when handling formalin.

1. Personnel should not be pouring formalin from one specimen container to another unless no other alternative exists.

2. Locations where formalin is used should be free of ignition sources, have posted signs warning of formaldehyde use, have ventilation systems with adequate capacity to maintain levels below permissible exposure limits

3. When handling formalin or containers with formalin, employees must wear proper PPE based on the potential for exposure.

TRAINING REQUIREMENTS

OSHA requires training to be performed at specific times and on certain occasions. The Practice’s training schedule is as follows:

A. Upon employment:1. All employees will receive training on the Hazard Communication Policy and Plan by

means of a: Training video and/or Written program and/or instruction by trainer

2. Methods and observations used to detect the presence or release of a hazardous chemical in the work area will be reviewed.

3. Measures new employees can take to protect themselves from the identified hazards will be reviewed along with any specific procedures the employer has implemented to protect the employees.

4. Explanation of the labeling system will be provided to the new employees.5. SDS are reviewed and explained with new employees before they engage in work

activities at their job site.

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6. Each new employee must demonstrate an understanding of the SDS of each chemical they will/may be required to handle.

B. When new products are received - Special training about new hazardous products will be performed when the product is received and prior to the release of the product for use in the office.

C. When there has been a modification of a procedure or technique for handling of the product by manufacturer or employer.

D. Upon receipt of any new or significant information regarding the hazards of a chemical currently being used within the practice. This information must be shared with the employee no later than within 3 months (90 days) of receiving the update.

E. When the employee makes a job change within Green Hills Direct Family Care.F. Annually as required by OSHA, with inclusion of:

1. Types of hazardous chemicals and medications in the setting2. Physical/Health risks of hazardous medications in the setting.3. Measures to protect themselves from these hazards.4. Appropriate workplace practices for special situation drugs, such as handling and

avoidance of vapors, gases, etc.5. Emergency procedures for spills and employee exposure to hazardous medications or

chemicals6. Personal protective equipment to wear when administering or handling hazardous

medications7. Labeling system for hazardous products and related SDS

WORKPLACE EXPOSURE

If an exposure to a hazardous medication, chemical or product occurs, the employee shall immediately notify their employer or Administrative Director. When appropriate, a determination will be made by the employer’s healthcare professional evaluator or designee as to the seriousness of the exposure and the appropriate treatment to be rendered. In emergent cases, the employee may seek recommended treatment at the nearest emergency healthcare facility. Necessary emergency or first aid procedures, specific to the product involved in the exposure, can be found in the product’s respective MSDS.

Types of exposures and methods to minimize exposure:

1. Ingestion Exposure : Chemicals may be harmful if swallowed. Never eat or drink in areas where chemicals are present.

2. Skin Exposure : Chemicals may be harmful is they come into contact with the skin. Use techniques that do not require direct handling of chemicals such as protective gloves or instruments (togs, etc.).

3. Chemical Vapor Exposure : Chemical vapors may be harmful if they are inhaled. Avoidance of breathing chemical vapors is best accomplished by replacing caps on containers immediately after dispensing and before mixing and using the chemical. This also avoids accidental spills of the chemical.

4. Mucous Membrane Exposure : Chemical may be harmful with they come into contact with mucous membranes such as eyes, nose and mouth. Employees should wear personal protective equipment (PPE) if there is a potential for exposure to chemical vapors. PPE can include, but not limited to eye protection, face shields, respirators as appropriate.

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HEALTHCARE PROFESSIONAL EVALUATION

An exposure determination is warranted whenever the following occurs:

1. An employee develops signs and symptoms associated with a hazardous chemical to which they may have been exposed.

2. When exposure monitoring revels an exposure level above the action level or permissible exposure limits (PEL) for a regulated substance.

3. When there is an accident in the work area such as a spill, leak or explosion or any other occurrence resulting in the likelihood of an exposure to a hazardous substance.

A medical examination will be performed by a licensed healthcare professional at no cost to the employee. Green Hills Direct Family Care will provide the following information to the examining healthcare professional:

1. Identity of the hazardous chemical(s) to which the employee may have been exposed.2. A description of the conditions under which exposure occurred, including quantitative

exposure data, if available3. Description of the signs and symptoms of exposure that the employee is experiences, if

applicable.

A written opinion shall be obtained from the healthcare professional who evaluates employees for this practice following an exposure incident. A copy of the written opinion will be provided to the employee within 15 working days of completion of the initial evaluation.

This written opinion shall not refer to any personal medical information of the employee. The opinion shall be limited to:

1. Notation that the employee has been informed of the evaluation results.2. Notation that the employee has been told about any medical conditions resulting from

exposure to the hazardous material.

REPORTING

The process for hazard exposure reporting will involve:

1. Documentation of the names of all employees exposed to the hazard.2. Documentation of the time and date of the incident.3. Documentation of the route of exposure and the circumstances under which the

exposure incident occurred.4. Documentation of the identification of the medication, chemical or product, when

feasible, and the manufacturer name, address, and phone number.5. Inclusion of copy of medication, chemical, or product MSDS in file.6. Documentation of the examination, testing, and results of medical treatment related to

exposure incident.7. Offer of appropriate counseling to the employee concerning precautions to take during

the period after the exposure incident.8. Evaluating the exposed employee for any subsequently reported illnesses relative to

the exposure incident.

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The employee will complete an Occupational Exposure Injury/Incident Report for any exposure incurred at the worksite. These forms will be maintained in the employee’s personnel file for the length of employment plus 30 years.

RECORDKEEPING

The employer shall establish and maintain an accurate and confidential record for each employee with an occupational exposure as required by OSHA Standard 29 CFR Part 1904. An accurate record for each employee with occupational exposure will be maintained using the following:

1. OSHA Forms: 300 Log of Work-related Injuries and Illnesses2. 300A Summary of Work-related Injuries and Illnesses3. 301 Injury and Illness Incident Report

The record shall include:

1. name and social security number of employee2. copy of the employee’s hepatitis B vaccination status including dates of vaccination3. documentation of the employee’s training status4. a description of the employee’s duties as they relate to the exposure incident5. documentation of the route(s) of exposure and circumstances under which the exposure

occurred including: location of the exposure incident procedure being performed at the time of the exposure engineering controls in use at the time of the exposure work practices followed description of any devices used during the exposure incident any PPEs in use at the time of the exposure

6. copy of test results of examinations, medical testing ordered, and follow-up procedures (consent must be obtained from exposed employee for employer access to HIV/HBV serological testing result documentation)

7. employer’s copy of the healthcare professional’s written opinion

The employer shall ensure that employee medical records are kept confidential and shall not be disclosed or reported to any person within or outside of the workplace without the express written consent of the employee except as required by the OSHA standard or law.

AVAILABILITY

All records including employee training and medical records will be made available and provided upon request for examination and copying to the subject employee, to anyone having written consent of the subject employee, and to the OSHA Director and/or Assistant Secretary, in accordance with the requirements of 29 CFR 1910.20.

The employer shall make the written hazard communication program available, upon request, to employees, their designated representatives, the Assistant Secretary (OSHA) and the Director (OSHA), in accordance with the requirements of 29 CFR 1910.20.

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TRANSFER OF RECORDS

The organization will comply with the requirements involving transfer of records set forth in 29 CFR 1910.20(h). If the organization ceases to do business and there is no successor employer to receive and retain the records for the prescribed period, the organization will notify the Director, at least three months prior to their disposal and transmit them to the OSHA Director, if required by the Director to do so, within that three month period.

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HAZARD COMMUNICATION STANDARD PICTOGRAM

As of June 1, 2015, the Hazard Communication Standard (HCS) will require pictograms on labels to alert users of the chemical hazards to which they may be exposed. Each pictogram consists of a symbol on a white background framed within a red border and represents a distinct hazard(s). The pictogram on the label is determined by the chemical hazard classification.

HCS Pictograms and HazardsHealth Hazard

Carcinogen Mutagenicity

Reproductive Toxicity

Respiratory Sensitizer

Target Organ Toxicity

Aspiration Toxicity

Flame

Flammables Pyrophorics

Self-Heating

Emits Flammable Gas

Self-Reactives

Organic Peroxides

Exclamation Mark

Irritant (skin and eye)

Skin Sensitizer

Acute Toxicity

Narcotic Effects

Respiratory Tract Irritant

Hazardous to Ozone Layer (Non-Mandatory)

Gas Cylinder

Gases Under Pressure

Corrosion

Skin Corrosion/Burns

Eye Damage

Corrosive to Metals

Exploding Bomb

Explosives Self-Reactives

Organic Peroxides

Flame Over Circle

Oxidizers

Environment(Non-Mandatory)

Aquatic Toxicity

Skull and Crossbones

Acute Toxicity (fatal or toxic)

For more information: Occupational

Safety and HealthAdministration

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LISTING OF HAZARDOUS CHEMICAL SUBSTANCES

Composed by:___________________________________ Date of Evaluation: ____/____/____ Location: ________________________________________________________________________

CHEMICAL NAME AND BRAND NAME

EFFECTS OF CHEMICAL ON TARGET

ORGAN

PPE REQUIRED

MANUFACTURER NAME & ADDRESS

COMMON USES

MSDS ON

FILE

Chemical Name: ______________________ Brand Name

Chemical Name:______________________Brand Name:

Chemical name:______________________Brand name:

Chemical name:______________________Brand Name:

Chemical Name:______________________Brand Name:

Chemical Name:______________________Brand Name:

Chemical Name:______________________Brand Name:

Write or print clearly.

File list in Central MSDS File. Post copy at site location (if desired)

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EMPLOYEE INFORMED REFUSAL OF POST ACCIDENT/INJURY- (NON PATHOGEN EXPOSURE)

I, _______________________________________________, as an employee of PRACTICE(First, Middle, Last Name, Title)

NAME on __________________, of ________________, 20___, was involved in an accident (day of week) (month)

when I (describe the accident or injury):

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Equipment involved: ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Due to this accident or injury, my employer has offered to provide me with post-accident/injury medical evaluation to assure that I have full knowledge of my degree of injury and whether I will require any treatment for my injury.

After receiving my employer’s offer for post-accident/injury medical evaluation, I have elected, on my own free will and volition, not to have a post-accident/injury medical evaluation. I have based this decision on my own personal reasons.

Employee Signature:___________________________________________________________

Name: (please print):___________________________________________________________First Middle Last

Address:_____________________________________________________________________Street Address

____________________________________________________________________________________City State Zip Code

Date of Signature: ______/_____/_____

Witness Signature/Title: ________________________________________________________

Note: Maintain this record for the duration of employment plus 30 years. Exception: If employee has been employed less than one year and that

employee’s records have been provided to the employee upon departure.

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EMPLOYEE INITIAL AND REFRESHER TRAINING -BLOODBORNE PATHOGENS AND HAZARD COMMUNICATION

Employee Name: _______________________________________________________

Initial Training Date

A. Employee has received instruction/training on _______/______/______Bloodborne Pathogens and Hazard Communication, has viewed the related videotapes, and has had theopportunity to ask questions and discuss the information presented.

B. Employee has read the Bloodborne Pathogen Exposure _______/______/______Control Plan and Policy and related OSHA regulations.

C. Employee has read the Hazard Communication Policy _______/______/______and Plan and related OSHA regulations.

D. Employee has been familiarized with the associated forms _______/______/______used for reporting any occupational exposure or injury.

E. Employee was instructed about specific chemical _______/______/______hazards in their workplace, including a review of the MSDSs of these hazardous chemicals for health hazard information, protective equipment warnings and spill hazard information.

F. Employee has been taken and passed a competency test on _______/______/______Bloodborne Pathogen and Hazard Communication.

Instructor’s Name: _________________________________ __________________ (Print clearly) (First/Last Name) (Title)

Instructor’s Signature: _________________________________ __________________

(First/Last Name) (Title)

Annual Refresher Training

This employee received refresher training on bloodborne pathogens, as well as, training on appropriate engineering controls and work practices, new safety policies and procedures, and reviews of MSDSs of any new and current chemicals that this employee may handle.

Instructor’s Name: _________________________________ _____/_____/_____

_________________________________ _____/_____/_____

Note: Retraining on past subjects is not required by OSHA.An annual MSDS review is recommended to familiarize employees with chemical safety.

Maintain this record for five years.

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ELECTRICAL SAFETY CONTROL PLAN

Electricity has become an essential part of the work environment. As a source of power, electricity is accepted without much thought to the hazards that can surround its use. Because it has become an essential part to the everyday functioning of the healthcare environment, it is often not treated with the respect that it deserves. One of the biggest misconceptions about electrical safety is that it takes high voltage to kill you. In fact, it is current, not voltage that causes electric shock. Electric shock occurs when current flows through your body. System voltages as low as 30 volts AC can supply enough current to shock or possibly even kill.

This Practice is committed to the early identification, isolation, and prevention of any electrical condition that could cause harm to its employees, patients, visitors or anyone else that could come in contact with an electrical device. The Electrical Safety control plan and policy is designed as a means to educate staff and physicians on the importance of electrical safety in the workplace, and deliver standard procedures to follow to ensure the use of electrical safety in their daily environment.

PROGRAM ADMINISTRATION

Green Hills Direct Family Care is responsible for the implementation of an active electrical safety program that will identify, and reduce risk factors in the workplace that can increase the probability of an electrical hazard occurrence. The Practice will maintain, review, and update the electrical safety control plan at least annually and whenever necessary to include new or modified tasks or procedures.

When a new employee is hired or an existing employee changes jobs or assumes tasks not previously performed, the following process will take place to ensure that they have been trained in the appropriate electrical safety procedures.

The employee’s job classification and the tasks and procedures that they will perform are evaluated in order to identify potential for electrical safety hazards.

The employee will be trained in the appropriate work practice controls to assure electrical safety policy is maintained.

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ELECTRICAL SAFETY POLICY

POLICY

It is the policy of Green Hills Direct Family Care to assess the electrical hazards to which an employee may potentially or actually be exposed in the course of a normal workday in the workplace. The purpose of any safety program is to prevent injuries and illnesses by removing their causes. It is the policy of the practice that all electrical equipment will be inspected prior to and during use in order to ensure and maintain an electrically safe environment.

PURPOSE

It is the responsibility of the Safety Officer to comply with OSHA Standard, Title 29, Federal Regulations Code 1910, Electrical Subpart S.

The employer is required to provide full support and authority to ensure compliance with this OSHA Standard is maintained.

EQUIPMENT

1. All equipment used in this practice meets the rating for the circuits to which they will be plugged in and the design requirements for the environment in which they are used.

2. Visually inspect all portable cord connected equipment and secure attachment to the plug before use.

3. Device cords should not be changed unless the replacement cord meets the electrical characteristics of the original. The cord may cause damage to the equipment if the electrical characteristics do not match that of the original cord.

4. Any appliance used at Green Hills Direct Family Care will be biomedical inspected before use. The appliance shall have a grounding conductor in its power cord, each appliance will come with a means of disconnection, such as an on/off switch prior to

disconnecting from the outlet. Each appliance used must have a rating for volts and amperes or volts and watts.

5. Electrical equipment will be grounded to allow another path from the tool or machine through which the current can flow to the ground, allowing another level of safety for the staff.

6. Circuit protectors will be used by person standing on the ground or on a conductive floor, as is found in an operating room, and in any damp or wet environment.

7. All breaker box switches are properly marked to identify function and areas served.8. An extension cord should be used ONLY if it has the correct electrical characteristics.

MAINTENANCE OF ELECTRIC EQUIPMENT

1. Biomedical Services The practice has contracted with ____________________ Biomedical Services for

biomedical inspection of all clinical equipment. Biomedical inspections will be conducted prior to use, every 6 months, and when clinical

equipment has returned following repair from manufacturer or servicing company.

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Copies of the inspection results of each piece of clinical equipment will be maintained in the Biomedical Equipment Manual.

A label is attached to each piece of equipment listing the condition at inspection, date of inspection, and inspector’s name.

2. Emergency Power Sources Emergency electric power source and associated equipment shall be regularly inspected,

tested and maintained. A written record of inspection, performance, exercising period, and repairs of emergency

power equipment shall be maintained. There will be annual polarity and tension testing and documentation for all electrical

receptacles within the practice.3. Electrical Power Cord Inspection

Each device is to be inspected for cord integrity, current leakage and ground wire integrity.

Electrical equipment that appears to be damaged or in poor repair, should not be used. A damaged cord requires replacement. A damaged plug requires replacement.

Any shocks from electrical equipment should be reported promptly to the Safety Officer.

EDUCATION AND TRAINING

Safety education will be provided for all employees at least on an annual basis to include information such as, but not limited to:

Definition related to electrical safety Key facts about electrical safety Risk factors for potential electrical hazards Prevention of electrical hazards Reporting of electrical hazards, electrical safety issues.

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MONTHLY ELECTRICAL HAZARD INSPECTION CHEKLIST

Electrical Inspection Areas

Hazard Present

Problem Reported

& Maintenance

Log Completed

Yes No Yes NoOutlets in good conditionOutlets are not overloaded (i.e. too many plugs)Outlets near sinks have ground fault circuit (GFI) interrupter installedOutlets and switches in working orderAdapters not used to convert three-pronged plugs to two- pronged plugsThree-pronged plugs intactAll electrical equipment located in such a manner as not to become wetElectrical equipment grounded appropriatelyWiring to all electrical equipment properly insulatedElectrical cords attached to any electrical equipment are not frayedElectrical cords attached to any electrical equipment do not have any exposed wiresElectrical cords attached to any electrical equipment are not showing signs of wearExtension cords are not used in the practiceSwitches in breaker box are properly marked to identify function and areas served

Signature: ________________________________________ Date Completed: ___/___/___

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ERGONOMICS CONTROL PLAN

Musculoskeletal disorders (MSDs) are injuries or disorders that occur to the muscles, nerves, tendons, joints, cartilage, or spinal discs over time. They are often caused by repetitive motion of the affected body part or by overexertion of the affected body part. Musculoskeletal disorders are one of the most frequently occurring types of occupational hazards affecting health care workers today. The combination of frequency, duration, and the stress of performing high-risk tasks that push the physical limits of what the body can handle, predispose healthcare workers to musculoskeletal disorders.

PROGRAM ADMINISTRATION

Green Hills Direct Family Care is responsible for the implementation of an Ergonomics program that will identify and reduce risk factors that can increase the probability of musculoskeletal disorders to its employees. Workers who experience pain and fatigue due to musculoskeletal disorders are less productive, more prone to make mistakes, more susceptible to further injury, and may be more likely to affect the health and safety of others.

When a new employee is hired or an existing employee changes jobs or assumes other tasks not previously performed, the following process will take place to ensure that they have been trained in the appropriate work practice controls:

The appropriate risk assessment will be completed to identify factors and conditions in the work place that may expose the employee to potential MSDs.

The risk assessment will be placed in the employees file and reviewed at least annually to ensure appropriateness.

The employee will be trained on proper safety policies and procedures and established work practices to help minimize the risk of developing a Musculoskeletal Disorder.

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ERGONOMICS POLICY

POLICY

Green Hills Direct Family Care will establish and implement an ergonomic program that will proactively identify and reduce risk factors that can increase the probability of musculoskeletal disorders (MSDs) of its employees. The program is designed to improve the health of its employees by minimizing ergonomic stressors. The objective of any safety initiative is to prevent injuries and illnesses by removing their causes. This objective is achieved by eliminating or reducing employee exposure to musculoskeletal disorder hazards.

PROGRAM IMPLEMENTATION

Implementation of the program will include data collection methodology, job analysis or risk assessment, hazard reduction and control measures, medical management, training and record keeping of injuries related to ergonomic stressors. The goals of the program will be to:

1. Decrease ergonomic hazards2. Reduce injuries and illnesses3. Ensure flexibility and innovation4. Assist in the prevention of musculoskeletal disorders

The steps of risk assessment include:

1. Looking for the hazards2. Deciding who might be harmed and how3. Evaluating the risks and deciding whether the existing precautions are adequate or

whether more should be done4. Recording the findings and distributing them to employees5. Reviewing the assessment and revising when applicable:

If work changes significantly If there is an accident When someone returns to work after sickness, injury, or suffers a change in their

health that could affect or be affected by their work

PROCEDURES

A risk assessment will be completed on all employees to determine potential hazards related to MSDs. The assessment will be placed in the employee’s health file and will be reviewed on at least an annual basis to ensure continued appropriateness.

A practice risk/hazard assessment will be completed to identify factors and conditions in the work place that may expose employees to potential MSDs. The risk assessment will be reported to the Practice safety officer. Any problematic issues identified through the risk assessment will be studied to ensure that the appropriate interventions are implemented to decrease the risk to the employee and to ensure that the engineering and administrative controls established remain effective.

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DEFINITIONS

Ergonomics : The fitting of the work place to the worker and examining the interaction between the worker and his or her environment. The term, as reference, refers to assessing those work-related factors that may pose a risk of musculoskeletal disorders and recommendations to alleviate them. Common examples of ergonomic risk factors are found in jobs requiring repetitive, forceful, or prolonged exertions of the hands; frequent or heavy lifting, pushing, pulling, or carrying of heavy objects; and prolonged awkward postures.

Ergonomic Stressors: Conditions that pose a biomechanical stress to the human body associated with increased risk for development of musculoskeletal disorders. Poor workplace designs can present ergonomic risk factors called stressors. These stressors include but are not limited to repetition, force, extreme postures, static postures, quick motions, contact pressure, vibration, and cold temperatures. Employee exposure to these stressors can cause injury or some type of MSD.

Repetition : Is the number of motions or movements that are performed per cycle or per shift

Force : Is the muscles used to produce force in order to perform necessary activities such as lifting, grasping, pinching, pushing, etc.

Extreme Postures : Is when muscles are required to work at a level near or at their maximum capacity.

Static Postures : A special type of awkward posture which occurs when a body part is not moving, but is still doing work. Examples include sitting in a chair or holding an object.

Contact Pressure : Is the pressure from resting part of the body against a sharp edge or corner. Resting the wrists or forearms on an edge of a desk while typing is one example.

Vibration : Exposure to local vibration occurs when a specific part of the body comes in contact with a vibrating object, such as a power hand tool. Exposure to whole-body vibration can occur while standing or sitting in vibrating environments or objects, such as when operating heavy-duty vehicles or large machinery.

Cold Temperatures : Reduce the natural elasticity of the body and reduce the sensation of touch (tactile feedback). In order to get the same amount of tactile feedback, an employee may exert more force than is necessary.

Musculoskeletal Disorder: Musculoskeletal disorders (MSDs) are disorders of the muscles, nerves, tendons, ligaments, joints, cartilage and spinal discs. MSDs do not include disorders caused by slips, trips, falls, motor vehicle accidents, or other similar accidents. Examples of MSDs include:

Carpal tunnel syndrome Rotator cuff syndrome De Quervain's disease Trigger finger, Tarsal tunnel syndrome Sciatica, Epicondylitis Tendinitis Raynaud's phenomenon Carpet layers knee Herniated spinal disc

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Low back pain

Work-related Musculoskeletal Disorder Hazard (WMSD Hazard): Work activities and/or work conditions in which ergonomic stressors are present that are reasonably likely to cause or contribute to a MSD.

Symptoms of Musculoskeletal Disorder: Symptoms of MSD identify that one or more ergonomic stressors may be present. There may be individual difference in susceptibility and symptoms among employees performing similar tasks. Any symptoms are to be taken seriously. The following list of symptoms can be but are not limited to:

Numbness Tingling Swelling Tightness Pain Stiffness Redness

Work Strategy Controls: When an ergonomic hazard has been identified, the practice will work at eliminating or minimizing the hazard. There are three general approaches to controlling ergonomic hazards; Engineering, Administrative and behavioral controls. In general, engineering controls are preferred as their goal is to reduce the presence of hazards.

Engineering controls : Changes made to the workstations, tools, and/or machinery that alter the physical composition of area or process, limiting the weight of instrument trays to 25 lbs., providing adequate lighting, having appropriate assistive patient handling equipment available.

Administrative Controls : Developing a culture of ergonomic safety, using patient care ergonomic assessment protocols, educating personnel in strategies to prevent musculoskeletal disorders, having adequate personnel present during patient handling and other situations resulting in ergonomic stress, changes made to regulate exposure without making physical changes to the area or process, for example taking frequent breaks and job rotations.

Behavioral Controls: Wearing nonskid footwear, eliminating clutter including removing wires/cords from the floor, covering equipment cables across the floor, keeping cabinet and room doors closed, cleaning up spill or debris as soon as possible, using anti fatigue mats, using lift teams/assistive devices to transfer or lift patients

RESPONSIBILITIES AND TRAINING

All employees are responsible for attending training on ergonomics via the annual training session and for following proper work practices. The Practice is responsible for evaluating and monitoring the ergonomic program including assessing the nature and extent of ergonomic hazards and recommending ways of minimizing or controlling these hazards. The Practice is responsible for providing sufficient resources to implement ergonomic recommendations in a timely manner as well as ensuring that employees are properly trained. The Practice will provide employees with an orientation including job specific training on:

Proper safety policies and procedures

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Established work practices Use of Personal protective clothing Job related risk factors Signs and symptoms of MSDs

All employees will be updated on ergonomic practices at the practice on at least a yearly basis through OSHA training. Records of the in-service education will be maintained in the employee personnel file.

MANAGEMENT

If an employee is experiencing any signs or symptoms of musculoskeletal disorders, the employee is to report their symptoms to the practice manager who will refer to the occupational health contractor for evaluation and treatment when applicable.

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GENERAL ERGONOMICS RISK FACTOR CHECKLIST

INSTRUCTION: USE THIS SHEET AS A PROMPTER. A “NO” RESPONSE INDICATES A POTENTAIL RISK FACTOR/PROBLEM THAT MAY REQUIRE INVESTIGATION.POLICIES AND PROCEDURES YES NO COMMENTS

Are ergonomic policies and procedures in place?Is incident reporting and investigation in place?Do staff members know how to report and injury or unsafe condition?Is management supportive and involved in health and safety program initiatives?CONSULTATION PROCESS

Is communication with employees conducted by meetings bulletin boards, in-service sessions, etc.?EDUCATION AND TRAINING

Is there an education and training strategy for ergonomic safety in place?Is ergonomic safety awareness information/training available to all employees?Is ergonomic safety training available at orientation?Is ergonomic safety job-specific training available?Is ergonomic safety refresher and in-service training available?HAZARD IDENTIFICATION AND RISK CONTROL STRATEGIESIs incident information captured in the database?Are incident statistics analyzed to identify trends?Are follow-up activities conducted to ensure implementation and evaluate effectiveness of ergonomic safety plans?Are risk assessments conducted based on priority needs including risk factor identification, assessment, and recommendation of controls?EQUIPMENT AND BUILDING DESIGN

Is there adequate equipment available for use?Is equipment in good working order?Is there a process for equipment repair in place and is it effective?Is staff aware of process for equipment repair?Is there a process for routine equipment maintenance?Is there adequate space to store equipment?Do work stations have adequate space?Are environmental aspects appropriate? (e.g. noise, temperature, lighting, clutter free hallways, etc.)EVALUATION, REVIEW AND PROMOTION

Is ergonomic safety information regularly promoted thru newsletters, staff bulletins, intranet postings, presentations, etc.?Are ergonomic program initiatives regularly reviewed to evaluate effectiveness?Are risk controls implemented, regularly reviewed to evaluate effectiveness?

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EMPLOYEE ERGONOMIC INJURY RISK ASSESSMENT SURVEY

This information will be used to determine potential ergonomic risk factors in your work setting and provide an opportunity for you to indicate problem areas and make suggestions for improvements.

1. Name:_________________________________________________________________________

2. Date: _________________________________________________________________________

3. Department or Work Area: ________________________________________________________

4. Occupation:____________________________________________________________________

5. Hours worked on average: _______ Per week:___________ Per shift: _________________

6. How often do you work overtime? Never Seldom Sometimes Always

7. Experience in this occupation: Less than 3 mths 3 mths to 1 year 1year to 5 years 5 years to 10 years Greater than 10 years

8. Have you received training on musculoskeletal injury (strain/sprains) with the employer? Yes No

9. What are the signs and symptoms of musculoskeletal injury (e.g. strain/sprains)? _______________________________________________________________________________________________________________________________________________________________________________

10. What should you do if you experience signs and symptoms of musculoskeletal injury? ___________________________________________________________________________________________________________________________________________________________________________

11. Are you aware of the risk factors in your workplace that may put you at risk of musculoskeletal injury (repetitive motion, sprains/strains)? If yes please describe: ____________________________________________________________________________________________________________________________________________________________________________________________

12. Please circle the appropriate number for each statement. Consider both mental and physical aspects of your job.

Strongly StronglyDisagree Disagree Undecided Agree Agree

a. I frequently perform repetitive motions 1 2 3 4 5b. My environment is conducive to falls or slips 1 2 3 4 5c. I perform frequent or heavy lifting 1 2 3 4 5d. I endure prolonged awkward positions 1 2 3 4 5e. I push, pull, or carry heavy objects 1 2 3 4 5f. There is adequate equipment to help with my job 1 2 3 4 5g. I am able to express physical concerns to my 1 2 3 4 5

Manager.

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13. Have you had any recurring pain or discomfort during the last year? Yes No

14. If yes, place an X on the drawing in the area(s) that you feel discomfort. For any area that you mark, rank the level of discomfort on a scale from 1 to 5. Place the number on the drawing beside the corresponding X.

1 = slight discomfort 2 3 4 5 = severe pain

15. For each area marked, what do you think causes the pain or discomfort?____________________________________________________________________________________________________________________________________________________

16. What job task or tasks that you perform are the most difficult or most in need of changing, and why?____________________________________________________________________________________________________________________________________________________

b. What do you suggest can be done?____________________________________________________________________________________________________________________________________________________

17. What other suggestions or ideas do you have for improving your workstation or work area?____________________________________________________________________________________________________________________________________________________

If you have additional comments, please provide them on the back of this sheet.

Thank you for filling in this survey!

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ERGONOMIC SAFETY SURVEY RESULTS

Date of Risk Assessment:________________

Signature: ____________________________________________________

Step 1 Step 2 Step 3 Step 4Hazards Found Who is affected? What are you already doing? What further action is necessary?_____________________ ___________________ ___________________________ ___________________________________________________ ___________________ ___________________________ ___________________________________________________ ___________________ ___________________________ ___________________________________________________ ___________________ ___________________________ ___________________________________________________ ___________________ ___________________________ ___________________________________________________ ___________________ ___________________________ ___________________________________________________ ___________________ ___________________________ ___________________________________________________ ___________________ ___________________________ ___________________________________________________ ___________________ ___________________________ ___________________________________________________ ___________________ ___________________________ ___________________________________________________ ___________________ ___________________________ ___________________________________________________ ___________________ ___________________________ ___________________________________________________ ___________________ ___________________________ ___________________________________________________ ___________________ ___________________________ ___________________________________________________ ___________________ ___________________________ ___________________________________________________ ___________________ ___________________________ ___________________________________________________ ___________________ ___________________________ ___________________________________________________ ___________________ ___________________________ ___________________________________________________ ___________________ ___________________________ ___________________________________________________ ___________________ ___________________________ ___________________________________________________ ___________________ ___________________________ ______________________________

Step 5 Review date:

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WORKPLACE VIOLENCE CONTROL PLAN

The culture of safety in the workplace is of increasing importance as workloads in healthcare increase, patient acuity increases, and emphasis on higher productivity increases. An organizations commitment to workplace safety is an important factor in influencing employee satisfaction and commitment to quality care.

Workplace violence is defined as violence or a threat of violence against workers. It can occur at or outside the workplace and is a growing concern for employers and employees throughout the nation. Healthcare workers are amongst the most vulnerable because of their continual contact with the public. Violence or threat of violence can occur as both verbal and/or physical abuse. It can occur from other staff, patients, patient families, staff families, or from physicians.

PROGRAM ADMINISTRATION

Green Hills Direct Family Care is responsible for the implementation of a workplace violence prevention program. Violence or the threat of violence in the workplace is strictly prohibited and will be taken seriously. It is the expectation of Green Hills Direct Family Care that all individuals, while representing the Practice will conduct themselves in a professional demeanor consistent with the policies in place.

The Practice will ensure that all staff are aware of the Violence in the Workplace Policy and understand that any claim of workplace violence will be investigated promptly. The Practice will make every effort to assist an employee experiencing threats of violence from a partner.

Education on violence in the workplace will occur when an employee is hired and at least on an annual basis along with mandatory safety education. A yearly analysis will occur to determine existing or potential threats for Workplace Violence.

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VIOLENCE IN THE WORKPLACE POLICY

POLICY

Green Hills Direct Family Care seeks to provide a work environment free from violence or threats of violence against individuals, groups, or employees, or threats against practice property-including partner violence that may occur on our property. This policy requires that all individuals on the premises or while representing the Practice, conduct themselves in a professional manner consistent with good business practices and in absolute conformity with non-violence principles and standards.

DEFINITIONS

Workplace Violence: A behavior, both single or a series of behaviors, in which an employee, former employee, member of the medical staff, vendor, patient or visitor to the workplace inflicts or threatens to inflict damage to property, serious harm, injury or death to others at the workplace.

Threat: The implication or expression of intent to inflict physical harm or actions that a reasonable person would interpret as a threat to physical safety or property.

Intimidation: The act of making other afraid or fearful through threatening behavior

Zero-tolerance: A standard that confirms that any behavior, implied or actual, that violates the policies and procedures of the Practice will not be tolerated.

Court Order: An order by a Court that specifies or restricts the behavior of an individual. Court orders may be used in matters involving domestic violence, stalking or harassment, among other types of protective orders, including temporary restraining orders.

Partner Violence: Abusive behavior occurring between two people in an intimate relationship. It may include physical violence, sexual, emotional, and psychological intimidation, verbal abuse, stalking, and economic control.

WORKPLACE ANALYSIS

Green Hills Direct Family Care will conduct yearly analysis to determine existing or potential hazards for workplace violence. The analysis will include, but not limited to:

1. Analysis and tracking records review medical, safety, worker’s compensation records, including the OSHA

Log of Related Injury and Illness (OSHA form 200) that may assist in determining workplace violence

2. Screening Surveys Use employee questionnaires to identify potential for violent incidents and

security measures that may need to be improved3. Analyze workplace security

a. Analyze incidents and relevant details of a reported situation and its outcomeb. Identify jobs or locations with the greatest risk of violencec. Identify processes and procedures that put employees at risk

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d. Note high-risk factors such as: Types of patients Physical risk factors related to building layout or design Isolated locations or activities Lighting problems Lack of phones or other communication devices Areas of easy, unsecured access Areas with previous security problems

e. Evaluate effectiveness of existing security measures determining if risk factors have been reduced or eliminated and actions taken to improve security if deficiencies noted.

f. Administrative and work practice controls will be implemented to minimize risk of workplace violence.

REACTION TO VIOLENCE IN THE WORKPLACE

Green Hills Direct Family Care strictly prohibits use of violence or threats of violence in the workplace and views such actions very seriously. The possession of weapons in the workplace, threats, threatening or menacing behavior, stalking, or acts of violence against employees, visitors, guests, or other individuals by anyone on practice property will not be tolerated. Violations of this policy will lead to disciplinary actions up to and including termination of employment and the involvement of appropriate law enforcement authorities as needed.

Any person who makes substantial threats, exhibits threatening behavior, or engages in violent acts on practice premises shall be removed from the property as quickly as safety permits, and may be asked to remain away from the practice premises pending the outcome of an investigation into the incident. People who commit these acts outside the workplace but which impact the workplace are also violating this policy and will be dealt with appropriately. Green Hills Direct Family Care reserves the right to respond to any actual or perceived acts of violence in a manner we see fit according to the particular facts and circumstances.

When threatening behavior is exhibited or acts of violence are committed, Green Hills Direct Family Care will initiate an appropriate response. This response may include, but is not limited to:

evaluation by Employee Assistance Professionals and/or external professionals, suspension and/or termination of any business relationship, reassignment of job duties, suspension or termination of employment, and/or criminal prosecution of the person/persons involved.

No existing policy, practice, or procedure established at the practice should be interpreted to prohibit decisions designed to prevent a threat from being carried out, a violent act from occurring, or a life-threatening situation from developing.

REPORTING PROCEDURE

Green Hills Direct Family Care personnel are responsible for notifying the Practice Manager of any threats which they have witnessed, received, or has been told that another person has witnessed or received, including those related to partner violence.

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Even without an actual threat, personnel should also report any behavior they have witnessed which they regard as threatening or violent when that behavior is job related or is connected to Practice. Employees are responsible for making this report regardless of the relationship between the individual who initiated the threat or threatening behavior and the person or persons who were threatened or were the focus of the threatening behavior.

Green Hills Direct Family Care understands the sensitivity of the information requested and has developed confidentiality procedures, which recognize and respect the privacy of the reporting employee(s). Consistent with the values of the Practice, people should take action in ways that maintain respect and dignity for individuals while acting in an accountable and swift manner to address the situation.

PARTNER VIOLENCE IN THE WORKPLACE

Green Hills Direct Family Care recognizes impact of partner violence on the workplace. The Practice is committed to heightening awareness of partner violence and providing guidance for employees and management to address the occurrence of partner violence and its effects on the workplace. In responding to partner violence, the Practice will maintain appropriate confidentiality and respect for the rights of the employee involved.

The Practice intends to make assistance available to employees involved in partner violence. This assistance may include:

confidential means for coming forward for help resource and referral information special considerations at the workplace for employee safety work schedule adjustments leave necessary to obtain medical, counseling, or legal assistance, and workplace

relocation, if available.

Green Hills Direct Family Care intends to publish, maintain, and post in locations of high visibility, a list of resources for survivors and perpetrators of partner violence.

Green Hills Direct Family Care will not deny job benefits or other programs to employees based solely on partner violence related problems. When employees confide that a job performance or conduct problem is related to partner violence, in addition to appropriate corrective or disciplinary action consistent with Practice policy and procedure, a referral for appropriate assistance should be made to the employee.

All individuals who apply for and obtain a protective or restraining order which lists Practice locations as being protected areas, must provide to the Practice manager, a copy of the petition and order.

LEAVE OPTIONS FOR EMPLOYEES EXPERIENCING THREATS OF VIOLENCE

Green Hills Direct Family Care will make every effort to assist an employee experiencing threats of violence. If an employee needs to be absent from work due to threats of violence, the length of the absence will be determined by the individual’s situation through collaboration with the employee and Practice manager

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Employees, along with the Practice manager, are encouraged to first explore paid leave options that can be arranged to help the employee cope with the situation without having to take a formal unpaid leave of absence. Depending on circumstances, this may include:

Arranging flexible work hours so the employee can seek protection, go to court, look for new housing, enter counseling, arrange child care, etc.

Considering use of sick time, job sharing, compensatory time, paid leave, informal unpaid leave, etc., particularly if requests are for relatively short periods.

SUGGESTED PROCEDURES FOR SAFETY AND PROTECTION OF EMPLOYEES EXPERIENCING THREATS OF VIOLENCE

Employee

Encourage the employee to save any threatening e-mail or voice-mail messages. These can potentially be used for future legal action, or can serve as evidence that an existing restraining order was violated.

The employee should obtain a restraining order that includes the workplace, and keep a copy on hand at all times. The employee may consider providing a copy to the police, his/her supervisor, security, or human resources [or appropriate individuals/departments within your Practice].

The employee should provide a picture of the perpetrator to reception areas and/or security.

The employee should identify an emergency contact person should the employer be unable to contact the victim.

If an absence is deemed appropriate, the employee should be clear about the plan to return to work. While absent, the employee should maintain contact with the appropriate Human Resources personnel

Employer

Arrange the victim to have priority parking near the building. Have calls screened, transferring harassing calls to security-or have the employee’s name

removed from automated phone directories. Limit information about employees disclosed by phone. Information that would help

locate a victim or indicates a time of return should not be provided. Relocate the employee’s workspace to a more secure area or another site. The employer should have trained EAP professionals or external professionals assist the

employee with development of a safety plan Work with local law enforcement personnel, and encourage employees to do so regarding

situations outside the workplace.

EDUCATION

Safety education will be provided for all employees, at least on an annual basis, to include information such as, but not limited to:

Description of unacceptable conduct Definition of workplace violence Key facts about workplace violence

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Risk factors for potential workplace violence Prevention of violence at the workplace Reporting of incidents

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WORKPLACE VIOLENCE SURVEY

This anonymous survey is being distributed to determine if there are any risks for violence in the workplace and to ascertain that policies and procedures are in place to protect our workers.

PHYSICAL ENVIRONMENTDo you feel safe at work? □ YES □ NO

Has your workplace been designed to protect you from workplace violence? □ YES □ NO

In your opinion, are there adequate measures to protect you? □ YES □ NO

If you answered NO to any of the previous questions, please indicate whether the following areas require improvement:

YES NO N/A

Lighting

Security checks or protocols (identification checks, sign in sheets, etc.)

Restrictions on public access to work areas (secured elevators, stairwells, etc.)Security in areas used to store personal belongings (locker rooms)

Security staff

Security of restrooms

Security of Parking Lot

Communication Procedures (for example, when and how to call for help)Layout of work areas (visual obstructions, unsecured objects and furniture, etc.)Security Devices (surveillance equipment, silent or sounding alarm, panic buttons, personal alarms, telephones, cell phones, etc.)Other:

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INCIDENTS AT WORK

Have you been hit, pushed, physically assaulted, or otherwise attacked while working at this organization?

Yes No

If you answered YES:

Where did the incident occur?

Did you report the incident? Yes No

How did you report the incident? Orally? In Writing? Who physically assaulted or otherwise attacked you?

client/customer member of the public co-worker partner/ex-partner manager/supervisor other:

Have you been sexually assaulted or been the target of a sexual incident while working at this organization?

Yes No

If you answered YES:

Where did the incident occur?

Did you report the incident? Yes No

How did you report the incident? Orally? In Writing? Who assaulted you?

client/customer member of the public co-worker partner/ex-partner manager/supervisor other:

Have you been threatened with physical harm (orally, in writing, or otherwise) while working at this organization?

Yes No

If you answered YES:

Where did the threat occur?

Did you report the threat? Yes No

How did you report the threat? Orally? In Writing? Who threatened you?

client/customer member of the public co-worker partner/ex-partner manager/supervisor other:

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VIOLENCE IN THE WORKPLACE SURVEY RESULTS

DATE OF RISK ASSESSMENT____/____/____

SIGNATURE:___________________________________________

Step 1 Step 2 Step 3 Step 4Hazards Found Who is affected? What are you already doing? What further action is necessary?_____________________ ___________________ ___________________________ ___________________________________________________ ___________________ ___________________________ ___________________________________________________ ___________________ ___________________________ ___________________________________________________ ___________________ ___________________________ ___________________________________________________ ___________________ ___________________________ ___________________________________________________ ___________________ ___________________________ ___________________________________________________ ___________________ ___________________________ ___________________________________________________ ___________________ ___________________________ ___________________________________________________ ___________________ ___________________________ ___________________________________________________ ___________________ ___________________________ ___________________________________________________ ___________________ ___________________________ ___________________________________________________ ___________________ ___________________________ ___________________________________________________ ___________________ ___________________________ ___________________________________________________ ___________________ ___________________________ ___________________________________________________ ___________________ ___________________________ ___________________________________________________ ___________________ ___________________________ ___________________________________________________ ___________________ ___________________________ ___________________________________________________ ___________________ ___________________________ ___________________________________________________ ___________________ ___________________________ ______________________________

STEP 5 REVIEW DATE ____/____/____

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VIOLENCE IN THE WORKPLACE ASSESSMENT

Completed By:_________________________________________ Date: ___/___/___

Physical Environment(Have you assessed the following?)

Yes No N/A ExistingControls

Recommended ControlsIdentify person(s) responsible and expected completion dates, if possible

Outside building and parking Lot

Entry Control and Security System

Reception and Waiting Areas

Public Counters

Interior design, hidden areas (utility rooms, etc.) and lighting

Stairwells and Exits

Elevators and Washrooms

Public Meeting Rooms, interview, treatment rooms, etc.

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PhysicalEnvironment

Yes No N/A Existing Controls Recommended Controls

(identify person(s) responsible and expected completion dates, if possible)

Isolated areas

Location of cash, goods, and medicines

Workplace location (shared building, neighboring businesses, neighborhood)

If used in your workplace, are security systems and individual security devices tested?

Is there a designated safe area where workers can go during a workplace violence incident?

Are there other measures or procedures needed to protect workers from the risks arising from the physical environment?

If your workplace has workplace security measures or individual security devices, are workers trained in their use?

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PhysicalEnvironment

Yes No N/A Existing Controls Recommended Controls

(identify person(s) responsible and expected completion dates, if possible)

Are workers and supervisors trained in all relevant measures and procedures that will protect them from violence associated with the workplace’s physical environment?Do clients have direct physical access to workers?

Can workers call for immediate help when workplace violence occurs or is likely to occur?

Does the workplace have a clean, uncluttered, welcoming atmosphere?

Is public access to the workplace restricted?

Where clients could become aggressive or violent, are there any objects or equipment that could be used to hurt people?

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PhysicalEnvironment

Yes No N/A Existing Controls Recommended Controls

(identify person(s) responsible and expected completion dates, if possible)

Are there designated rooms for meeting with clients?

Is there a place for workers to safely store their personal belongings?

Do workers work at times of increased vulnerability, such as late at night, early in the morning, or at very quiet times of day?Are there any other risks associated with the physical environment and contact with the public?Do you have procedures to identify, evaluate, and inform workers about specific high-risk clients, situations, or locations?

Do you have procedures for workers to follow when dealing with strangers or intruders?

Do you have procedures for workers to follow when dealing with aggressive or violent clients or members of the public?

Are there other measures or procedures needed to protect workers from the risks of contact with clients?

Are workers and supervisors trained in all relevant measures and procedures for protecting themselves from workplace violence associated with client contact?

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WORKPLACE VIOLENCE INCIDENT REPORT

Date of Incident: ___/___/___ Received via: □ Verbal-direct □ Verbal-Indirect □ Mail □ Email □ Other: ______________________

TYPE OF INCIDENT: (1 or more as appropriate)Threat: Intimidation: Communicated directly to victim Stalking Communicated to another person Engaging in actions intended to frighten, coerce, or induce duress Other (Specify)______________________________ Other (Specify)________________________________Physical Attack: Property Damage: Hitting, fighting, pushing, or shoving Damage to Practice Property Use of object as weapon Damage to personal property Use of weapon such as gun or knife Other (Specify) ________________________________ Other (Specify)_______________________________VICTIM(S) INFORMATION: Total number of victim(s): _______________________________

If victim(s) sustained physical or traumatic/emotional injury indicate the number(s) in each of the following categories: Physical injury Trauma/Emotional injury Medical care required EAP/Psychological care provided Workers ‘Compensation claim(s) filed Other:______________________________________________Gender: Race: Age: Male White Hispanic 18-21 40-55 Female Black Asian American 22-29 Over 55

Native American Other_____________________ 30-39PERPETRATOR INFORMATION: (If known) Employee Spouse/Family Member Supervisor Customer/Client/Vendor Former Employee StrangerGender: Race: Age: Male White Hispanic 18-21 40-55 Female Black Asian American 22-29 Over 55

Native American Other____________________ 30-39If perpetrator was employee, supervisor, or former employee, complete the following:Employment Classification: Length of employment: Management Administrative Support < 1 yr. 10 - 15 yrs Professionals (MD, RN, CRNA) Other:___________________________ 1 - 5 yrs 15 - 20 yrs Technicians 5 - 10 yrs >20 yrs

Have other incidents been reported regarding this perpetrator? YES, If so how many?________ NO

Reason for Incident: (If known, check all that apply) Conflict with co-worker(s) Alcohol/drugs in the workplace Conflict with supervisor Alcohol/drugs in the workplace Conflict with patient/family of patient/visitor Mental health problems Conflict with vendor/HCIR Racial tension Family/domestic dispute Dismissal Receiving a poor performance appraisal OtherINITIAL RESPONSE: (Check all that apply) Situation defused EAP consulted Security called Employee placed on Investigation Status Police called Other (Specify)

ACTION TAKEN: (Check all that apply) Written warning

Dismissal Suspension Restraining order Transferred employee Charges filed Mediation Other: (Specify)______________________________________________________

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No action taken:____________________________________________________________________________________

Report Submitted by:__________________________________________ Date:_________

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TUBERCULOSIS EXPOSURE CONTROL PLAN

Nearly one-third of the world's population is infected with Tuberculosis (TB), nearly 9 million develop the disease, and it kills almost 2 million people per year. In the United States, approximately 13,000 new cases of TB are reported annually, and 650 persons die from TB each year. TB is the leading cause of mortality among persons infected with HIV. In 2004, the OSHA proposed standard for Tuberculosis, was withdrawn. Respiratory protection from Tuberculosis is now covered under OSHA's Respiratory Standard 29 CFR 1910.134 as well as Recordkeeping, and General Duty Clause Section 5(a)(1). OSHA General Duty Clause Section 5(a)(1)states: "Each employer shall furnish to each of his employees employment and a place of employment which are free from recognized hazards that are causing or are likely to cause death or serious physical harm to his employees."

Tuberculosis (TB) is a contagious disease caused by the bacteria Mycobacterium tuberculosis. M Tuberculosis is usually transmitted only through air, not by surface contact. An individual who has TB in his throat or larynx can release droplet nuclei into the air by coughing, sneezing, singing, shouting, talking or breathing. These particles are invisible to the naked eye and are approximately 1 to 5 microns in size. Droplet nuclei can remain airborne in a room for a long period of time, until they are removed by natural or mechanical ventilation. TB is spread when an individual inhales one or more of these particles and becomes infected with TB. Anyone who shares air with an individual who has infectious TB disease is at risk; however, TB is not usually spread by brief contact.

Except on rare occasions, TB is infectious only when it occurs in the lungs or larynx. TB that occurs somewhere else in the body is usually not infectious, unless that individual has TB in the lungs at the same time. In general persons with TB should be considered infectious until the person has:

Had 3 negative acid fast bacilli (AFB) sputum smear results obtained 8 to 24 hours apart, with at least one being in the early morning

Shown to have clinical signs of improvement as a result of at least 2 weeks of anti-tuberculosis treatment

Been determined to be noninfectious by a physician knowledgeable in the treatment of TB

This practice and its TB exposure control plan is committed to the early identification, isolation and treatment of persons with known and/or active tuberculosis. This manual is designed as a means to educate staff and physicians on methods of exposure prevention and to deliver standard procedures to follow when exposure to TB occurs. The Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health Care Facilities, 2005, Center for Disease Control, MMWR will be followed as directive on tuberculosis infection control. At a minimum, the TB infection control plan should include administrative controls, environmental controls, and a respiratory-protection program.

This exposure control plan shall be available at the worksite for the employee to access and reference. A copy may be requested by the employee and provided by the employer within 15 days of the request. An employee covered by this TB Exposure Control Plan is defined as any full-time, part-time, temporary, contract or per diem employee.

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PROGRAM ADMINISTRATION

Green Hills Direct Family Care is responsible for the implementation of the TB Exposure Control Plan. This practice will maintain, review, and update the TB Exposure Control Plan at least annually, and whenever necessary to include new or modified tasks or procedures.

When a new employee is hired or an existing employee changes jobs or assumes other tasks not previous done, the following process will take place to ensure that they have been trained in the appropriate work practice controls:

The employee’s job classification and the tasks and procedures that they will perform are evaluated in order to identify position where occupational exposure is likely to occur.

Employee will be trained in work practice controls associated with the new job classification.

Those employees who are determined to have “occupational exposure” to active tuberculosis must comply with the procedures and work practices outlined in this document and by OSHA Standard, 29 CFR 1910.1030.

EXPOSURE POTENTIAL-DETERMINATION

OSHA requires employers to perform an exposure determination concerning which employees may incur occupational exposure during the course of daily activities throughout their employment. The exposure determination at the practice will be specific to those employees who are exposed to patients with unknown diagnosis of TB at the time of treatment or procedure as it is the policy of the practice to not perform procedures on patients with known active disease.

This exposure determination is required to list all job classifications in which all employees have occupational exposure. Additionally, a list of job classifications should be included in which only some employees have occupational exposure along with specific tasks and procedures in which occupational exposure occurs for these specific classifications.

ENGINEERING AND WORK PRACTICE CONTROLS

Standard precautions that are employed for all patient contact, as defined in this compliance manual under the bloodborne pathogens exposure control plan, will be observed. One of the most critical risks for health-care–associated transmission of M. tuberculosis in health-care settings is from patients with unrecognized TB disease who are not promptly handled with appropriate airborne precautions.

Individuals or patients who are suspected of being infected with active TB will be removed from the waiting area or any common area and placed in a well-ventilated, isolated exam room by themselves. Doors or windows in the exam room will be kept closed at all times, except during entry and exit by select personnel. All standard precautions will be maintained and prompt evaluation of the patient will occur.

Medical instruments and equipment, including medical waste are usually not involved in the transmission of M Tuberculosis. Standard precautions will be followed with the disinfection and cleaning of instruments and equipment. Disinfection and cleaning should only be performed after the appropriate amount of time for air ventilation. Surfaces will be cleaned and wiped down with

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an “appropriate disinfectant”. The use of a detergent germicide capable of inactivating many pathogens is an acceptable method of cleaning.

RESPIRATORY PROTECTION CONTROLS Use of respiratory protection can further reduce risk for exposure of HCWs to infectious droplet nuclei that have been expelled into the air from a patient with infectious TB disease. This practice will implement the appropriate respiratory protection procedures based on results of the practice risk assessment.

TB RISK ASSESSMENT

Every health-care setting should conduct initial and ongoing evaluations of the risk for transmission of M. tuberculosis, regardless of whether or not patients with suspected or confirmed TB disease are expected to be encountered in the setting. The TB risk assessment determines the types of administrative, environmental, and respiratory-protection controls needed for a setting and serves as an ongoing evaluation tool of the quality of TB infection control and for the identification of needed improvements in infection-control measures

RISK CLASSIFICATION TO DETERMINE NEED FOR TB SCREENING AND FREQUENCY OF SCREENING HCWS

Risk classification should be used as part of the risk assessment to determine the need for a TB screening program for HCWs and the frequency of screening. The three TB screening risk classifications are low risk, medium risk, and potential ongoing transmission.

The classification of low risk should be applied to settings in which persons with TB disease are not expected to be encountered, and, therefore, exposure to M. tuberculosis is unlikely. This classification should also be applied to HCWs who will never be exposed to persons with TB disease or to clinical specimens that might contain M. tuberculosis.

The classification of medium risk should be applied to settings in which the risk assessment has determined that HCWs will or will possibly be exposed to persons with TB disease or to clinical specimens that might contain M. tuberculosis.

The classification of potential ongoing transmission/high risk should be temporarily applied to any setting (or group of HCWs) if evidence suggestive of person-to-person (e.g., patient-to-patient, patient-to-HCW, HCW-to-patient, or HCW-to-HCW) transmission of M. tuberculosis has occurred in the setting during the preceding year. Evidence of person-to-person transmission of M. tuberculosis includes 1) clusters of TST or BAMT conversions, 2) HCW with confirmed TB disease, 3) increased rates of TST or BAMT conversions, 4) unrecognized TB disease in patients or HCWs, or 5) recognition of an identical strain of M. tuberculosis in patients or HCWs with TB disease identified by deoxyribonucleic acid (DNA) fingerprinting.

If uncertainty exists regarding whether to classify a setting as low risk or medium risk, the setting typically should be classified as medium risk

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EMPLOYEE TB SCREENING AND TESTING

Employee screening will be performed by this practice and include review of medical history with a focus on past respiratory illnesses and related symptoms, any current symptomology, any recent exposure(s) to known or suspected TB individuals, any history of positive reactions to previous tuberculin skin tests and any current pharmacological therapies being used specifically for TB treatment.

All HCWs, regardless of risk classification, should receive baseline TB screening upon hire, using two-step TST or a single BAMT to test for infection with M. tuberculosis. Personnel already known to have a reactive TST shall not be required to be tested; however a chest x-ray may be ordered and performed at the appropriate intervals or a physician’s statement regarding absence of active disease. This will also be applied to those employees with allergies to the TST serum or who have received overseas immunization for TB.

The TST test results will be read by the designated, trained personnel between 48-72 hours after injection. Self-reading of the TST results shall not be accepted.

The result of the test will be based on the presence or absence of an induration, recorded in millimeters, at the injection site and established practice criteria. This criteria will be based on the purpose of the test; the prevalence of TB infection in the population being tested; the immune status of the host; and, any previous receipt of BCG immunization.

Any reaction (positive or negative) to TST test will be documented in the employee’s individual health record, including date of injection, site of administration, amount of serum injected, lot number and expiration date, description of the injection site/ reaction, and the measurement in millimeters of the transverse diameter of the induration. Any individual with a positive reaction will be referred to the local hospital or health department for follow-up diagnostic testing, such as chest radiography and AFB sputum smears, and treatment (i.e., INH) if necessary.

Any personnel determined to have active pulmonary or laryngeal TB will be prohibited from duty and entry into the practice until there is indication that they are noninfectious. Documentation must be provided from an employee’s healthcare provider stating they are noninfectious based on the following criteria: a) adequate therapy is being received, b) the cough has resolved, and c) results of three acid-fast bacilli sputum smears collected on three different days are negative, prior to re-entry to the practice and return to duties.

Upon resuming work duties, the employee will be required to produce periodic documentation from the employee’s healthcare provider that shows effective drug therapy is being maintained and that AFB sputum smears remain negative. If at any time during the anti-TB therapy the employee discontinues current treatment and exhibits signs of infectiousness, they shall be excluded from the workplace until non-infectiousness can be proven.

INVESTIGATION OF TUBERCULIN SKIN TEST CONVERSION /POSITIVE IGRA IDENTIFIED DURING ROUTINE SCREENING

If a skin-test conversion or positive IGRA is identified for an employee during a routine screening, the following actions will be taken by this practice:

The employee and/or screening facility will notify the practice of the positive results.

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The employee will be evaluated promptly for active TB at a local hospital equipped for evaluation and treatment of TB or the local health department.

The employee, if diagnosed with active TB, will be prohibited from duty and entry into the practice and will be subject to the stated requirements of this policy prior to returning to duty.

A history of the exposure will be taken to assist in determining the source individual. If the source individual is identifiable and has a history of latent TB or is currently exhibiting

active TB signs/symptoms, the individual’s drug susceptibility will be documented, if known. No investigation will occur if the employee was exposed and infected outside of the practice. If the history is suggestive of a practice source or a source individual is identified as being in

the practice, contacts of the suspected source individual shall be identified and evaluated. The practice shall be evaluated for cause(s) of exposure and transmission, including review

of patient identification processes, engineering controls, work practices, and infection control policies.

Interventions shall be developed specific to each identified cause of exposure and transmission.

If no source individual in the practice can be identified and the history does not suggest the exposure occurred outside of the practice, laboratory and infection-control records will be reviewed to identify all patients and/or personnel who have suspected or confirmed active TB.

If screening of contacts identifies additional TB test conversions and results of the investigation show no issues or problems with internal procedures, the public health department or other persons with expertise in TB infection control will be considered for consultation.

EMPLOYEE COUNSELING, POST-EXPOSURE EVALUATION AND FOLLOW-UP

An “exposure incident” is defined by OSHA as a specific eye, mouth, other mucous membrane, non-intact skin, or parenteral contact with blood or OPIM that results from the performance of an employee’s duties. When an “exposure incident” occurs, it should be reported to the office manager and the attending physician before the end of the work shift during which the “exposure incident” occurred. All employees who incur an “exposure incident” will be offered post-exposure evaluation, prophylaxis and follow-up in accordance with the OSHA standard 1910.1030. This process will involve:

Documentation of the names of all employees involved in rendering assistance during the incident, the source individual, and any other persons exposed.

Documentation of the time and date of the incident. Documentation of the route of exposure and the circumstances under which the exposure

incident occurred. Documentation of the identification of the source individual, when feasible. Providing the results of the testing of the source individual to the exposed employee and

informing the employee of the applicable laws and regulations concerning disclosure of the identity and infectious status of the source individual.

Administering a Tuberculin skin test to the employee. Referring employee to collaborative facility (locally equipped hospital and/or health

department) for appropriate TB evaluation, including physical examination and testing, and diagnosis and treatment, as warranted.

Offering appropriate counseling to the employee concerning precautions to take during the period after the exposure incident.

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Evaluating the exposed employee for any subsequently reported illnesses relative to the exposure incident.

Administering a Tuberculin skin test 3 months after initial exposure to any employee who tested negative immediately after exposure incident.

Administering a Tuberculin skin test 3 months after 1st 3 month testing, if 1st 3-month test resulted in a conversion.

All counseling in relation to the identification of an employee as infected with the TB bacteria shall be completed by the local hospital and/or local health department.

HEALTHCARE PROFESSIONAL EVALUATION

A written opinion shall be obtained from the healthcare professional who evaluates employees for this practice following an exposure incident. A copy of the written opinion will be provided to the exposed employee within 15 working days of completion of the original evaluation. This written opinion shall not refer to any personal medical information of the employee. The opinion shall be limited to:

1. Notation that the employee has been informed of the evaluation results.2. Notation that the employee has been told about any medical conditions resulting from

exposure to the M. tuberculosis 3. Information provided to all healthcare professionals at the practice responsible for evaluating

employees after an exposure incident will have the following information available:

a copy of the OSHA Regulation 29 CFR 1910.1030 Bloodborne Pathogens and 1910.139 Respiratory Protection from M. tuberculosis;

a description of the exposed employee's duties as they relate to the exposure incident documentation of the route(s) of exposure and circumstances under which exposure

occurred results of the source individual's testing if available; and all medical records relevant to

the appropriate treatment of the employee including vaccination status

EDUCATION AND TRAINING

Training for employees will be conducted or provided by the employer (1) prior to or at the time of initial assignment of the employee to tasks where occupational exposure may occur; (2) within 90 days to the employee after an effective date for any changes to the standard; and (3) at least annually to the employee thereafter. Retraining will be provided by the employer to the employee when any changes in procedure or tasks occur which affect occupational exposure and/or annually. Training for all identified employees shall include, at a minimum:

1. A general explanation of the epidemiology and symptoms of M. tuberculosis transmission 2. Explanation of the TB Exposure Control Plan and the means by which the employee can

obtain a copy of the written plan 3. Description of specific risks for TB infection among persons exposed to M. tuberculosis4. Review of medical surveillance requirements5. Discussion of any pharmacotherapy treatment such as INH or other chemoprophylactic

agents6. Criteria for early identification of patients who may be at risk for being potential carriers of

TB

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7. Explanation of the use and limitations of engineering control methods and work practices which will be used at this practice

8. Explanation of the basis for selection of PPEs at this practice9. Proper selection, wearing, adjustment, appropriate fit check, and disposal of the particulate

filter mask as appropriate.10. Benefits and limitations of the particulate filter mask selected for use by the practice11. Instruction on how to recognize an inadequately functioning particulate filter mask 12. Identification of signs and labels used to identify infectious or potentially infectious materials13. Information on the appropriate actions to take and persons to contact should a patient with

suspected TB be admitted to the practice, including the method of reporting the incident and the medical follow-up that will be made available

14. Explanation of the procedure to follow for post-exposure evaluation, prophylaxis and follow-up

15. Healthcare workers responsibility to seek prompt medical evaluation if a PPD test conversion occurs or if symptoms develop that could be caused by TB

16. Opportunity for interactive questions and answers with the person conducting the training session.

Training records shall include the dates of training, the contents or summary of the training program, the names and qualifications of the person(s) conducting the training sessions, and the names and job titles of the persons attending the training sessions.

RECORDKEEPING

The employer shall establish and maintain an accurate and confidential record for each employee with an occupational exposure. The record shall include:

1. name and social security number of employee2. copy of employee’s previous and most recent PPD test results including dates3. documentation of the employee’s training status4. a description of the employee’s duties as they relate to the exposure incident5. documentation of the exposure and circumstances under which the exposure occurred

including: location of the exposure incident procedure being performed at the time of the exposure engineering controls in use at the time of the exposure work practices followed a description of any devices used during the exposure incident any PPEs in use at the time of the exposure

6. copy of test results of examinations, medical testing ordered, and follow-up procedures (consent must be obtained from exposed employee for employer access to HIV/HBV serological testing result documentation)

7. employer’s copy of the healthcare professional’s written opinion

The employer shall ensure that employee medical records are kept confidential and shall not be disclosed or reported to any person within or outside of the workplace without the express written consent of the employee except as required by the OSHA standard or law.

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TUBERCULOSIS EXPOSURE CONTROL POLICY

POLICY

It is the policy of Green Hills Direct Family Care to provide guidelines for health care workers at this practice to minimize the contact with all real and potential contamination found in potentially TB-infectious materials (OPIM) in accordance with the Center for Disease Control (CDC) and Occupational Safety and Health Administration (OSHA).

This exposure control policy and procedure shall be reviewed by all employees and made available at the worksite for the employee to access and reference. A copy may be requested by the employee and provided by the employer within 15 days of the request. An employee covered by this TB Exposure Control Policy and Procedure is defined as any full-time, part-time, temporary, contract or per diem employee.

RESPONSIBILITES

The health care worker is responsible for following the TB exposure control plan and isolating a patient suspected of having TB from other persons in the practice. The health care worker is responsible for protecting themselves by wearing the highest level of respiratory (mask) protection available to them, adhere to the use of appropriate PPEs, perform hand hygiene before and after touching the patient, coming in contact with any respiratory secretions and when removing gloves.

The Practice staff is responsible for adhering to the TB Exposure Control Plan and the use of personal protective equipment (PPE). Appropriate hand hygiene will be performed as defined in the exposure control policy.

This Practice will be responsible for providing all supplies and equipment needed for carrying out these precautions. The organization will clean, launder, and dispose of personal protective equipment at no cost to the employee. Also, repairs or replacements of PPEs will be provided at no cost to the employee.

EXPOSURE POTENTIAL AND RISK ASSESSMENT

This practice or designee will perform and document an exposure potential determination for its employees. This determination will include documentation of the potential for employee:

contact with known or suspected TB-infected patient; handling of known or suspected TB-infected patient sputum or body fluids; cleaning or handling contaminated equipment or instrumentation; and all other situations of care or service where a potential may exist for exposure.

This practice or designee will perform and document a risk assessment for the practice annually. This assessment will include documentation of:

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review of the community TB profile (Consult the local or state TB-control program to obtain epidemiologic surveillance data necessary to conduct a TB risk assessment for the health-care setting)

number of known TB patients treated at the practice for the previous 5 years Determine the types of environmental controls that are currently in place, and determine if

any are needed in the setting Conduct periodic reassessments (annually, if possible) to ensure 1) proper implementation of

the TB infection-control plan; 2) prompt detection and evaluation of suspected TB cases; 3) prompt initiation of airborne precautions of suspected infectious TB cases before transfer; 4) prompt transfer of suspected infectious TB cases; 5) proper functioning of environmental controls, as applicable; and 6) ongoing TB training and education for HCWs.

evaluation of current infection control parameters through evaluation of medical records of known TB patients seen at this practice

Risk assessment should be performed to determine the need and the frequency for a TB screening program for the practice’s employees.

The CDC Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health-Care Setting, 2005, defines risk categories as:

Medium Risk- All HCWs should receive baseline TB screening upon hire, using two-step TST or a single

BAMT to test for infection with M. tuberculosis. After baseline testing for infection with M. tuberculosis, HCWs should receive TB screening

annually (i.e., symptom screen for all HCWs and testing for infection with M. tuberculosis for HCWs with baseline negative test results).

HCWs with a baseline positive or newly positive test result for M. tuberculosis infection or documentation of previous treatment for LTBI or TB disease should receive one chest radiograph result to exclude TB disease. Instead of participating in serial testing, HCWs should receive a symptom screen annually. This screen should be accomplished by educating the HCW about symptoms of TB disease and instructing the HCW to report any such symptoms immediately to the occupational health unit. Treatment for LTBI should be considered in accordance with CDC guidelines

Low Risk- All HCWs should receive baseline TB screening upon hire, using two-step TST or a single

BAMT to test for infection with M. tuberculosis. After baseline testing for infection with M. tuberculosis, additional TB screening is not

necessary unless an exposure to M. tuberculosis occurs. HCWs with a baseline positive or newly positive test result for M. tuberculosis infection (i.e.,

TST or BAMT) or documentation of treatment for LTBI or TB disease should receive one chest radiograph result to exclude TB disease (or an interpretable copy within a reasonable time frame, such as 6 months). Repeat radiographs are not needed unless symptoms or signs of TB disease develop or unless recommended by a clinician

High Risk- Testing for infection with M. tuberculosis might need to be performed every 8–10 weeks

until lapses in infection control have been corrected, and no additional evidence of ongoing transmission is apparent.

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The classification of potential ongoing transmission should be used as a temporary classification only. It warrants immediate investigation and corrective steps. After a determination that ongoing transmission has ceased, the setting should be reclassified as medium risk. Maintaining the classification of medium risk for at least 1 year is recommended.

ENGINEERING AND WORK PRACTICE CONTROLS

Engineering and work practice controls will be utilized to eliminate or minimize exposure to employees at the practice. Review of engineering and work practice controls will be performed annually to identify any new procedures or products that would further minimize the potential for biohazard exposure in the workplace.

Prompt initiation of TB precautions will be carried out for anyone within the practice suspected of having infectious TB. The following engineering and work practice controls for TB exposure control will be utilized at this practice:

1. Initial patient medical histories and periodic check-ups shall document patient response to questions governing previous diagnosis of TB disease and treatment or any current symptoms suggestive of TB.

2. Individuals or patients who are suspected of being infected with active TB will be removed from the waiting area or any common area and placed in a well-ventilated, isolated exam room by themselves. Doors or windows in the exam room will be kept closed at all times, except during entry and exit by select personnel.

3. A warning will be posted outside the exam room comprised of a signal word or biological hazard symbol, with a major message such as “Airborne Isolation” and a description of the necessary precautions.

4. Individuals/patients who are suspected of being infected with active TB will be fitted with a surgical mask and given instructions to keep the mask in place.

5. Entry into the room with the infected or suspected TB patient shall be limited to select office personnel and immediate family.

6. Family members will be given general instructions on TB precautions and how to use and wear the appropriate respiratory protection prior to entry into the isolation room.

7. Designated personnel and family will enter into and exit from the exam room through one specified doorway. This doorway will be selected such that it will minimize the exposure and airflow to the remaining portions of the practice.

8. Appropriate respiratory protection specific for TB will include masks such as NIOSH-approved N-95, N-99 and N-100 particulate respirators.

9. The suspected or infected TB patient may remove the mask for nose blowing (using disposable tissues) and ingestion/inhalation of medications, with immediate replacement of mask over mouth and nose upon completion of the activity.

10. Specimens from the suspected/infected TB individual will be placed in biohazard-labeled containers which prevent leakage during collection, processing, storage and transport of the specimen.

11. Any contamination that occurs outside of the primary container will require replacement of the original container into a second container which prevents leakage during handling, processing, storage, transport or shipping, and is labeled and color-coded appropriately.

12. Disposable equipment used in direct contact with infected or suspected TB infectious materials will be discarded in biohazard-labeled waste containers in the room where the suspected/ TB-infected individual is located.

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13. Reusable instruments will be cleaned meticulously before sterilization or high-level disinfection shall be completed.

14. Reusable instruments such as those that come in contact with the mucous membranes of the TB infected patient, i.e., endoscopes, bronchoscopes, ET tubes, will be either sterilized or cleansed with a high-level disinfectant that destroys vegetative organisms, most fungal spores, tubercle bacilli, and small nonlipid viruses.

15. Standard/Universal precautions and NIOSH-approved respiratory protection specific for TB will be used when performing any cough-inducing or aerosol-generating procedures on infected or suspected TB patients, including processing of specimens.

16. After the patient leaves the room, the room should remain closed for up to one hour before anyone enters. However, adequate wait time may vary depending on ventilation rate of the room.

PERSONAL PROTECTIVE EQUIPMENT

The following personal protective equipment and other materials and equipment are used by this practice for prevention of exposure to potentially infectious body fluids, such as TB-infected sputum. Gloves should be worn when it can be reasonably anticipated that the employee will be involved in high hazard procedures such as aerosolized medication treatment, bronchoscopy, endoscopy, sputum induction, endotracheal intubation and suctioning, or may have hand contact with blood, OPIM, mucous membranes, and/or non-intact skin, especially when performing vascular access procedures and handling or touching contaminated items or surfaces.

1. Disposable (single use) gloves such as surgical or examination gloves will be replaced as soon as practical when contaminated or as soon as feasible if they are torn, punctured, or when their ability to function as a barrier is compromised.

2. Disposable (single use) gloves will not be washed or decontaminated for reuse.3. Gloves are not required to be worn when patient contact is not anticipated unless any activity

being undertaken will result in contact with a contaminated or potentially contaminated surface.

4. Gloves will be changed between each patient contact.5. Thorough hand hygiene will be required:

Between patient contacts. If contaminated with blood or other infectious materials. Prior to putting gloves on Following glove removal. Prior to eating. After using toilet facilities. After covering the nose and mouth when coughing or sneezing. After trash and/or infectious waste disposal. Anytime hands are visibly soiled.

NIOSH-approved respiratory protection, such as the N-95, N-99 and N-100 particulate respirators, are recommended by the CDC for use in the protecting personnel from exposure to or inhalation of airborne tuberculosis bacilli.

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1. The appropriate (as defined above) respiratory protection shall be worn from the time of entry until exit from any isolation procedure or exam room occupied by a symptomatic suspected or confirmed TB patient.

2. Respiratory protection will be disposed of in the appropriate receptacle, which will be placed immediately outside the designated entrance of isolation room.

3. The appropriate (as defined above) respiratory protection in combination with eye protection devices, such as goggles or glasses with solid side shields, or chin-length face shields, will be worn during high hazard procedure or whenever splashes, spray, spatter, or droplets of mucous or other potentially infectious materials may be generated and eye, nose, or mouth contamination can be reasonably anticipated.

PRE-EXPOSURE TUBERCULIN EMPLOYEE SKIN TESTING

TB screening, using TST or a single BAMT to test for infection with M. tuberculosis will be made available, at no cost to the employee, to all current employees who have been identified as having “occupational exposure” and to any new employees prior to exposure within ten working days prior to initial assignment. Exceptions: 1) Any employee who has previously received the Tuberculin skin test within the last 12 months with negative results and no current symptomatology, or 2) Any employee who is known to be PPD positive (converted) due to exposure but currently not exhibiting any TB symptoms. A two-step baseline TST or a single BAMT shall be used for new employees who have an initially negative PPD test result and who have not had a documented negative TB skin test result during the preceding 12 months.

All positive reactions to PPD Tuberculin tests will be documented in the employee’s individual health record.

All employees who decline to receive the Tuberculin skin test must sign a denial of consent form stating their decision not to receive the test.

Any employee who has been determined to have active pulmonary or laryngeal TB will be prohibited from duty and entry into the practice until there is indication they are noninfectious. Documentation of their noninfectious status will be provided by the employee’s healthcare provider stating they are noninfectious based on the following criteria: a) adequate therapy is being received, b) the cough has resolved, and c) results of three acid-fast bacilli sputum smears collected on three different days are negative, prior to re-entry to the practice and return to duties. Periodic documentation from the employee’s healthcare provider will be requested to show effective drug therapy is being maintained and that AFB sputum smears remain negative.

MANAGEMENT OF PERSONNEL

The office/practice manager or designee should be immediately notified of any significant exposure. An employee incident form must be initiated and should include an accurate description of the incident and any necessary source patient information. This practice or designee will determine the significance of the exposure, complete the written form and confirm the patient's current TB status.

If the source individual has been diagnosed with TB, has other evidence of TB infection, has a positive Tuberculin skin test or has positive TST history in conjunction with current

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symptomatology, the source individual must be isolated and then transferred to a local hospital or health department equipped for isolation, diagnosis and treatment of TB-infected individuals as soon as feasible. If the source individual’s Tuberculin skin test is negative, the source individual must be retested in 1-3 weeks. Consent and pre/post- test information will be provided to the source individual by the office/practice manager or designee.

Although the source individual may initially test negative, further follow-up of exposed personnel by administration shall be necessary.

If the source patient cannot be identified, a decision by Green Hills Direct Family Care regarding appropriate follow-up should be individualized, based upon type of exposure and the known information about the likelihood of infectivity of the source individual.

If the source individual has not been tested previously for TB, a Tuberculin skin test will be administered with the source individual’s consent (and preferably an order from their attending or primary physician). If the attending or primary physician cannot be contacted in a timely manner, then this practice will order the test.

Tuberculosis exposure testing will be available at no cost to the employee and administered to obtain a baseline measurement to any employee who experiences a TB exposure. Employees will be required to sign a consent form for the Tuberculin skin test administration prior to the test being performed and after receiving proper education about the test.

All specimens and/or results of employee testing will be handled by this practice or designee in strict confidence.

MANAGEMENT OF PERSONNEL WITH POSITIVE PPD TUBERCULIN TEST

Employees are encouraged to report any previous or current positive Tuberculin skin test results to this practice for confidential referral to qualified facility for evaluation, diagnosis and treatment, as necessary. This referral will be done regardless of where in the practice the employee is working.

In keeping with policies of this practice, personnel will refrain from entering the workplace and engaging in direct care or treatment of any patients within the practice until such time that:

adequate therapy is being received their cough has resolved and results of 3 acid-fast bacilli sputum smears collected on three different days are negative.

If latent TB-infected personnel experience any exacerbating symptoms, they must immediately report this to their supervisor and refrain from all direct patient care and from handling patient-care equipment until the current episode/condition resolves. Resolution of the condition is based upon documentation of:

Adequate therapy being received, Resolution of cough, and Negative results of three acid-fast bacilli sputum smears collected on three different days.

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INVESTIGATION OF PPD CONVERSIONS IDENTIFIED DURING ROUTINE SCREENING

If a skin-test conversion is identified for an employee during a routine screening, the following actions will be taken by this practice:

1. The employee and/or screening facility will notify this practice of the positive results.

The employee will be evaluated promptly for active TB at a local hospital equipped for evaluation and treatment of TB or the local health department.

The employee, if diagnosed with active TB, will be prohibited from duty and entry into the practice and will be subject to the stated requirements of this policy prior to returning to duty.

A history of the exposure will be taken to assist in determining the source individual. If the source individual is identifiable and has a history of latent TB or is currently

exhibiting active TB signs/symptoms, the individual’s drug susceptibility will be documented, if known.

No investigation will occur if the employee was exposed and infected outside of the practice.

If the history is suggestive of a practice source or a source individual is identified as being in the practice, contacts of the suspected source individual shall be identified and evaluated.

The practice shall be evaluated for cause(s) of exposure and transmission, including review of patient identification processes, engineering controls, work practices, and infection control policies.

Interventions shall be developed specific to each identified cause of exposure and transmission.

If no source individual in the practice can be identified and the history does not suggest the exposure occurred outside of the practice, laboratory and infection-control records will be reviewed to identify all patients and/or personnel who have suspected or confirmed active TB.

If screening of contacts identifies additional TB test conversions and results of the investigation show no issues or problems with internal procedures, the public health department or other persons with expertise in TB infection control will be considered for consultation.

2. All active TB cases identified by this practice will be reported to the public health department.

EMPLOYEE COUNSELING, POST EXPOSURE EVALUATION AND FOLLOW-UP

Following a report of a TB exposure incident, the practice will make immediately available to the exposed employee a confidential medical evaluation and follow-up treatment, as necessary, through referral to a local equipped hospital or health department. This practice’s documentation and report of the exposure incident will include at least the following elements:

1. Documentation of the names of all employees involved in rendering assistance during the incident;

2. Documentation of the date and time of the exposure

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3. Documentation of the route(s) of exposure and the circumstances under which the exposure incident occurred;

4. Identification and documentation of the source individual, unless the practice can establish that identification is not feasible or prohibited by state or local law;

5. Collection and testing of source individual’s and exposed employee’s sputum for TB status after consent is obtained from each respective individual;

6. Notification to the employee of the source individual’s test results;7. Notification to the employee of the applicable laws and regulations concerning disclosure of

the identity and infectious status of the source individual;8. Administration of a PPD Tuberculin skin test to the employee;9. Referral of employee to collaborative facility (locally equipped hospital and/or health

department) for appropriate TB evaluation, including physical examination and testing, and diagnosis and treatment, as warranted.

10. Post-TB exposure prophylaxis and/or treatment, when medically indicated;11. Symptomatology, evaluation and treatment of any subsequently reported illnesses;12. Appropriate counseling concerning precautions to take during the period after the exposure

incident

INFORMATION PROVIDED TO HEALTHCARE WORKER

All healthcare professionals employed by or contracted with the practice, which are responsible for administering the practice’s PPD Tuberculin testing, are provided with a copy of the regulation, 1910.1030 Bloodborne Pathogens.

All healthcare professionals at the practice responsible for evaluating employees after an exposure incident will have the following information available:

a copy of the OSHA Regulation 29 CFR 1910.1030 Bloodborne Pathogens; a description of the exposed employee's duties as they relate to the exposure incident; documentation of the route(s) of exposure and circumstances under which exposure

occurred; results of the source individual's blood testing if available; and all medical records relevant to the appropriate treatment of the employee including

vaccination status.

HEALTHCARE PROFESSIONALS EVALUATION

The organization will obtain and provide the employee with a copy of the evaluating healthcare professional's written opinion within fifteen days of the completion of the evaluation.

The healthcare professional's written opinion for post-exposure evaluation and follow-up will be limited to the following information:

Notation that the employee has been informed of the results of the evaluation; Notation of whether TB prophylaxis or treatment is indicated for an employee; and Notation that the employee has been told about any medical conditions resulting from

exposure to TB which require further evaluation or treatment.

All other findings or diagnoses will remain confidential and will not be included in the written report.

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INFORMATION AND TRAINING:

1. All employees with potential for occupational exposure will participate in a TB training program which is provided during working hours and at no cost to the employee.

2. Training will be provided at the time of initial assignment to duties where occupational exposure may occur, within 90 days after an effective date for any changes to the standard, and at least annually thereafter.

3. The organization will provide training material appropriate in content and vocabulary to educational level, literacy, and language of the employees. Additional training will be provided to employees when changes such as modification of tasks or procedures or institution of new tasks or procedures are initiated.

4. All healthcare professionals conducting training sessions will be knowledgeable in the subject matter covered by the elements contained in the training program.

RECORDKEEPING

Medical Records - An accurate medical record for each employee with occupational exposure will be maintained.

1. This record will include: the name and social security number of the employee copy of the employee's PPD result status including the dates of all the PPD tests and any

medical records relative to the employee's ability to receive the test a copy of all results of examinations, medical testing, and follow-up procedures a copy of any healthcare professional's written opinion as required by this standard a copy of the information provided to the healthcare professional as required by this

standard2. All employee medical records are kept confidential and are not disclosed or reported without

the employee's express written consent to any person within or outside the workplace except as required by this standard or as required by law.

3. Medical records of employees who have worked for less than one (1) year need not be retained beyond the term of employment if they are provided to the employee upon termination of employment. The organization will maintain records required for at least the duration of employment plus thirty years.

Training Records

1. Training records will include the following information: The date(s) of the training sessions; The content or summary of the training session(s); The name(s) and qualifications of person(s) conducting the training; The name(s) and job title(s) of all persons attending the training sessions.

2. Training records will be maintained for three years from the date on which the training occurred.

3. Employee training records are not considered confidential.4. Employee training records will be provided to the employee within 15 working days of

request.

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Availability

All records including employee training and medical records will be made available and provided upon request for examination and copying to the subject employee, to anyone having written consent of the subject employee, and to the OSHA Director and/or Assistant Secretary in accordance with 29 CFR 1910.20.

Transfer of Records

1. The organization will comply with the requirements involving transfer of records set forth in 29 CFR 1910.20(h).

2. If the organization ceases to do business and there is no successor employer to receive and retain the records for the prescribed period, the organization will: Notify the Director at least three months prior to their disposal, and Transmit the records to the OSHA Director, if required by the Director to do so within

that three month period.

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EMPLOYEE PPD TESTING FORM

Employee Name:______________________________________________________________________

Job Title: _______________________________ Date of Employment: ____/___/____

Work Location: __________________________

Does this employee have a history of positive(converted) PPD Reaction NO_____ YES ____

Does this employee have a history ofOccupational exposure to TB? NO_____ YES ____

Does this employee have a history ofActive TB? NO_____ YES ____

Initial PPD Tuberculin Skin Test: Administration date: ___/___/___(Required for all employees with Interpretation date: ___/___/___Potential for occupational exposure) Skin Test Reaction: _______mm induration

Two Step PPD Test: Administration date: ___/___/___(Required for all new employees with Interpretation date: ___/___/____Potential for “occupational exposure” Skin Test Reaction: _______mm indurationWhose initial test was negative)

Yearly PPD Test: Year:__________(Required for all identified employee Administration date: ___/___/___At low risk for occupational exposure) Interpretation date: ___/___/___

Skin Test Reaction: _______mm induration

Year:__________Administration date: ___/___/___Interpretation date: ___/___/___Skin Test Reaction: _______mm induration

Year:__________Administration date: ___/___/___Interpretation date: ___/___/___Skin Test Reaction: _______mm induration

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EMPLOYEE TB EXPOSURE POTENTIAL AND RISK DETERMINATION FORM

This form is used to determine your potential exposure levels to Mycobacterium tuberculosis. Special safety measures are required by OSHA if you have more than one potential exposure incident per year. Presume you are not using protective equipment when reviewing the tasks and procedures.

Name: ________________________________________________ Date: ____/____/____

Job Title: ______________________________________________

Work Location: _________________________________________

EXPOSURE POTENTIAL DETERMINATION

Do you engage in direct patient contact and/or care?

Do you perform or assist with any high hazard procedures?

Do you clean or handle contaminated equipment or instruments?

Does this employee work in an area where there is a cluster of positive TB tests?

RISK ASSESSMENT

Date of Most Recent PPD-Tuberculin Skin Test: Results:

Have you ever had an exposure to a known TB-infected individual?

Have you ever had an exposure to a known TB-infected individual’s sputum or body tissue?

Have you ever been referred for evaluation of signs/symptoms suggestive of TB?

Yes _____ No _____

Yes _____ No _____

Yes _____ No _____

Yes _____ No _____

____/____/_____

Negative ___ Positive ___ mm induration

No _____ Yes _____ If yes, when? ____/____/_____

No_____ Yes______

No _____ Yes _____

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Have you ever been diagnosed with TB?

Have you ever been treated for TB?

Have you ever been vaccinated with BCG?

No _____ Yes _____ If yes, when? ____/____/_____

No ______ Yes _____

No _____ Yes _____ If yes, when? ____/____/_____

Please review the following tasks and procedures. Check the tasks you perform. Write in other tasks which are not noted here but which might expose you to tuberculosis.

[ ] High risk aerosolizing procedures such as bronchoscopy, endoscopies, induced-sputum [ ] Contact with saliva with or without blood present [ ] Catheterizations, cauterizations, lacerations[ ] Perform or assist in a surgical procedure [ ] Phlebotomy, injections, and specimen collection - handling blood specimens and other body fluids[ ] Clean, maintain and sterilize instruments[ ] Housekeeping tasks – toilets, floors, emptying of infectious wastes[ ] Housekeeping and laundry – blood-soaked or urine-soaked linens[ ] Other tasks of potential exposure which you do but are not noted here:______________________________________________________________________________________________________________________________________________________________________

Safety Officer’s Determination of the Exposure Risk: (Check one)Low Risk ____ Intermediate Risk ____ High Risk ____

[ ] This employee does not require TB pathogen protection.

[ ] This employee does require TB pathogen protection. The employee has been provided with protective clothing and personal training, has received the PPD Tuberculin skin testing required, and has been instructed by a video training tape, discussion, policy review and copies of related regulations.

Date:______/______/_____ Safety Officer: ___________________________________________

Reviewed on: _______________________ 201__Reviewed on: _______________________ 201__Reviewed on: _______________________ 201__Reviewed on :________________________ 201__

Note: Maintain This Record and Review Annually

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EMPLOYEE TB EXPOSURE POTENTIAL AND RISK DETERMINATION

Tuberculosis exposure Testing shall be conducted using these schedules based on the above assessment and determination in combination with the practice assessment.

Low Risk Occupational Group – after initial testing on employment, Ongoing testing not needed unless exposure to M. Tuberculosis occurs or the risk assessment results change.

Health care workers who will never be exposed to persons with TB disease or to clinical specimens that might contain M Tuberculosis.

Medium Risk Occupational Group – Testing Performed annually Health Care workers will or will possibly be exposed to persons with TB disease or to

clinical specimens that might contain M Tuberculosis. At this practice all clinical staff, receptionists, front office staff who may have contact

with potentially exposed persons, central sterilization staff are considered as part of the medium risk group.

High Risk/Potential ongoing transmission Occupational Group – Testing Performed Every 3 Months

Evidence suggests person-to-person transmission of M. Tuberculosis has occurred during the preceding year

Clusters of TST or IGRA conversions Health care worker with confirmed TB disease Unrecognized TB disease in patients or health care workers

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TB OCCUPATIONAL EXPOSURE INJURY/INCIDENT REPORT

Name/Title of Injured/Exposed Individual: ________________________________________________________

Date of Injury: ____/____/____ Date Injury Reported: ____/____/____Time of Injury: _____________ Time Injury Reported: _____________

If individual injured is NOT an employee of Green Hills Direct Family Care, please indicate employer name, address, and phone number:

Name: __________________________________________________________________________

Address: ______________________________________ Phone: ___________________________

________________________________________________________________________________

Employer: ______________________________________________________________________

FACTS OF EXPOSURE/INJURY/INCIDENT

Describe the activity being performed by the employee when the exposure or injury occurred. (Be specific. Identify if the employee was utilizing equipment or instrumentation or handling material at the time of exposure.) ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Explain how the incident occurred. List any events that may have or did lead to and result in the exposure or injury. ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Describe the nature of the injury. Be specific in identifying the body area(s) injured. ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Describe any potential action(s) that could be taken to prevent or minimize this type of incident. _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

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EXPLANATION

A member of our practice staff was accidentally exposed to your blood or body fluid. In order to comply with recommendations of the Centers for Disease Control and this practice’s TB Exposure Control Plan and Policy, we are requesting your consent to administer to you a PPD Tuberculin test. This test may show whether or not you have been exposed to TB.

Your consent will enable our practice to provide necessary care and assist in the proper medical management of the exposed employee. It is important that you understand the following:

1. We cannot test you for exposure to TB without your consent.2. You will not be charged for the PPD Tuberculin Skin Test administration or interpretation/reading of

the test results.3. This signed consent and the test results will be kept CONFIDENTIAL and will NOT be placed in

your medical record.

The test results will be reported to the physician counseling the Green Hills Direct Family Care employee.

CONSENT/DECLINE

I have been informed about the implications and limitations of the test for exposure to the TB pathogen. I have been able to ask questions about the test and my questions were answered to my satisfaction. I understand the benefits and risks of the PPD Tuberculin test.

[ ] I hereby consent to have the PPD Tuberculin testadministered to me.

[ ] I would like to know the results of the PPD Tuberculin test. I understand that I will be notified by the physician counseling Green Hills

Direct Family Care employee.

______________________________________________Patient’s Signature

______________________________________________If patient unable to consent, authorized signature

______________________________________________Relationship to patient

______________________________________________Witness Signature/Title

[ ] I hereby decline to have the PPD Tuberculin test administered to me.

__________________________________ Date

__________________________________ Date

__________________________________ Date

__________________________________ Date

EXPLANATION OF AND CONSENT OR DECLINE FOR TB TESTING OF SOURCE INDIVIDUAL FOLLOWING EMPLOYEE EXPOSURE

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PRACTICE TB RISK DETERMINATION FORM

Number of total employees at Practice Site: ___________________________________________

Number of employees at Practice with Occupational Exposure potential: ____________________

20____ Results of Public Health Department community TB profile for _______________ County:________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Number of Identified TB patients examined at this practice in 20____: __________ Number of total employees with positive PPD reactions: _____% of total: _____ Number of employees with Occupational Exposure

potential with positive PPD reactions: ______% of total _____

List of specific areas/locations within Practice:1. ___________________________ # Employees/Area Total w/+ PPD Reactions: ___/___2. __________________________ # Employees/Area Total w/+ PPD Reactions: ___/___3. __________________________ # Employees/Area Total w/+ PPD Reactions: ___/___4. __________________________ # Employees/Area Total w/+ PPD Reactions: ___/___5. __________________________ # Employees/Area Total w/+ PPD Reactions: ___/___

Has there been evidence of Person to Person TB transmission at this Practice? No___ Yes___If Yes when? _____/_____/_____

If Yes, what was the cause of transmission?_____________________________________________________________________________________________________________________________________________________________________________________________________________

Was the cause of the transmission identified and corrected? No___ Yes ___If Yes, How? _____________________________________________________________________If No, Why? _____________________________________________________________________

What, if any measures need to be initiated/instituted to correct transmission cause? _____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Risk Evaluator’s Signature: _____________________________________ Title:_______________

Date of Risk Evaluation: _____/_____/_____

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PRACTICE TB RISK DETERMINATION CRITERIA FORM

Minimal Risk Criteria Review of community TB profile shows no patients with TB in community Review of practice records shows no TB patients examined at this practice

Very Low Risk Criteria Review of community TB profile and office profile shows TB patients in either

practice, community or both No significant difference in PPD conversion rates between areas/locations or

occupational groups within Green Hills Direct Family Care No significant difference between previous and current PPD conversion rates for

areas/locations or occupational groups within Green Hills Direct Family Care No cluster of PPD conversions among healthcare workers within Green Hills Direct

Family Care No evidence of person-to-person transmission within Green Hills Direct Family

CareLow Risk

Review of community TB profile and office profile shows TB patients in either practice, community or both

No significant difference in PPD conversion rates between areas/locations or occupational groups within Green Hills Direct Family Care

No significant difference between previous and current PPD conversion rates for areas/locations or occupational groups within Green Hills Direct Family Care

No cluster of PPD conversions within areas/locations or occupational groups within Green Hills Direct Family Care

No evidence of person-to-person transmission within areas/locations or occupational groups within Green Hills Direct Family Care

Fewer than six TB patients seen at practice during preceding yearIntermediate Risk

Review of community TB profile and office profile shows TB patients in either practice, community or both

No significant difference in PPD conversion rates between areas/locations or occupational groups within Green Hills Direct Family Care

No significant difference between previous and current PPD conversion rates for areas/locations or occupational groups within Green Hills Direct Family Care

No cluster of PPD conversions within areas/locations or occupational groups within Green Hills Direct Family Care

No evidence of person-to-person transmission within areas/locations or occupational groups within Green Hills Direct Family Care

Six or more TB patients admitted to area/location during preceding yearHigh Risk

Review of community TB profile and office profile shows TB patients in either practice, community or both

One or more of the following: Significant difference in PPD conversion rates between areas/locations or

occupational groups within Green Hills Direct Family Care; OR

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Significant difference between previous and current PPD conversion rates for areas/locations or occupational groups within Green Hills Direct Family Care; OR

Cluster of PPD conversions within areas/locations or occupational groups within Green Hills Direct Family Care; OR

Evidence of person-to-person transmission within areas/locations or occupational groups within Green Hills Direct Family Care

No identification of cause of transmission

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TB STANDARD POST TRAINING PROGRAM TEST

Name: ________________________________________________ Date: _____/_____/______

Job Title: ______________________________________________Number Correct: ____/ 15

Instructions: Read each statement. Circle the appropriate response.

1. Patients identified by the receptionist as having active TB signs and symptoms should have a professional staff member evaluate the patient before placing a mask on the patient and isolating them from the other patients in the waiting room.A. TrueB. False

2. The number of TB cases in the U.S. is increasing with new multi-drug resistant strains being isolated.A. TrueB. False

3. Individuals with high risk for TB include all of the following except: A. Immunocompromised individualsB Older individuals with decreased healthC. Healthcare workers who use proper universal precautionsD. Persons living with an individual who has active untreated TB

4. A PPD test is:A. Routine used to detect a person’s exposure to M. tuberculosisB. Is administered through an injection under the surface of the skinC. Cannot infect a person with tuberculosis because it is a protein derivativeD. All of the above

5. Signs and symptoms of TB include all of these except: A. FeverB Night sweatsC DiarrheaD Cough

6. Personal protective equipment must be worn any time a health care worker anticipates exposure to a TB-infected patient’s sputum or biopsy tissue. A. TrueB. False

7. Exposure to TB:A. Can be prevented with good handwashingB. Does not require being reported to the employerC. Is rare and only occurs in third world countriesD. Can occur when there is late identification and non-isolation of persons with related

signs and symptoms8. An individual with active TB is considered noninfectious:

A. After his/her cough subsidesB. After receiving appropriate pharmacotherapy treatment and is compliant with

medication regimenC After three consecutive sputum smears are negative

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D. All of the above

9. Tuberculosis (TB) is spread through:A. Hand to hand contactB. Direct inhalation of expelled breath/cough/mucous spray from an infected individualC. An infected needlestickD. None of the above

10. Reusable instruments used for an infected TB patient for invasive procedures, such as bronchoscopy:A. Require meticulous cleaning or sterilization with a high-level disinfectantB. Do not require any specialized cleaningC. Should not be used on any other patients and should be appropriately discardedD. Do not need to be sterile for use on a TB patient when used to access the bloodstream or

normally sterile areas of the body11. Standard/Universal Precautions require that health care workers must take special

precautions only with patients who have an infectious disease, such as TB, hepatitis or HIV.A. TrueB. False

12. NIOSH-approved N-95, N-99, and N-100 masks are to be used by patients who are suspected of or identified as having active TB.A. TrueB. False

13. . A two-step baseline is used for employees who have an initially negative TB skin test result and who have not had a documented negative TB skin test result during the preceding 12 months. A. TrueB. False

14. Education and training for employees on TB must:A. Occur prior to or at the time of initial assignment of the employee to tasks where

occupational exposure may occurB. Within 90 days after an effective date for any changes to the standard, plan or policy of

this practiceC. At least annuallyD. All of the above

15. An individual infected with tuberculosis (TB):A. Can be treated with INHB. May exhibit signs and symptoms of persistent cough, fever and night sweatsC. Can be diagnosed with a combination of a PPD test, CXR, and sputum sampleD. All of the above

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TB PRE/POST TRAINING TEST ANSWER KEY

PRE TRAINING PROGRAMTEST ANSWERS

1. T2. F3. T4. F5. T6. F7. F8. T9. T10. T

POST TRAINING PROGRAMTEST ANSWERS

1. B2. A3. C4. D5. C6. A7. D8. D9. B10. A11 B12. B13. A14. D15. D

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EMPLOYEE INITIAL AND REFRESHER TRAINING RECORD- MYCOBACTERIUM TUBERCULOSIS TRAINING

Employee Name: ________________________________________________________________

Initial Training Date:

A. Employee has read the TB Exposure ControlPlan and related OSHA regulations ____/____/____

B. Employee has read the TB Exposure Control Policy ____/____/____

C. Employee was instructed about the specific workplaceEngineering controls and work practices, including a Review of the protective equipment required for careof the TB patient. ____/____/____

Instructor’s Name: ________________________________________ ___________________(Print Clearly) (First/Last Name) (Title)

Instructor’s Signature: _____________________________________ __________________(First/Last Name) (Title)

Annual Refresher Training

This employee received refresher training on M. Tuberculosis pathogen, as well as, training on appropriate engineering controls and work practices, new safety policies, and Tuberculosis screening options.

Instructor’s Name: ______________________________________ ____/____/____ ___________________________________ ____/____/____

Note: Retraining on past subjects is not required by OSHA.

Maintain this record for 5 years.

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References:

CDC- Workbook for Designing, Implementing, and Evaluating a Sharps Injury Prevention Workbook.

OSHA Standard 1910 Subpart I- personal protective equipment; Standard 1910.1030-Bloodborne Pathogens

Department of Transportation regulations for Medical Waste

OSHA Standard 1910.1200(a)(1) Hazard Communication

OSHA Brief, Hazard Communication Standard: Labels and Pictograms, pgs. 1-9

OSHA Standard 1910.301(b),(c),(e)

NFPA 70, National Electric Code

OSHA 29 CFR 1910; 1953: Ergonomics Programs- Preventing Musculoskeletal Disorders

Ergonomics: The Study of Work; US Department of Labor, OSHA 3125: 2000

Elements of Ergonomics Programs- A Primer Based on Workplace Evaluations of Musculoskeletal Disorders; US Department of Health and Human Services, CDC and NIOSH, March 1997.

Guidelines for Preventing Workplace Violence for Health Care & Social Service Workers, OSHA 3148-01R 2004 CDC Guidelines for Preventing the Transmission of Mycobacterium Tuberculosis in Health-Care Setting, 2005 pgs 5-79.

CDC Guidelines for Preventing the Transmission of Mycobacterium tuberculosis in Health-Care Settings, 2005 pgs. 5-79.

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NEW REPORTING REQUIREMENTS

Effective January 1, 2015, the Occupational Safety and Health Administration (OSHA) has updated its rule regarding injury and illness recording and reporting. These changes affect all employers with no exemptions to this new rule, regardless of other reporting and record keeping exemptions.

The following injuries and illness reporting MUST be reported to OSHA within the specified timeframes without exception:

All work-related fatalities within eight (8) hours of occurrence. Only fatalities occurring within 30 days of the work-related incident must be reported to OSHA.

All work related in-patient hospitalizations within twenty-four (24) hours, but only if the hospitalization occurs within twenty-four (24) hours of the work-related incident

All work-related amputations or loss of an eye within twenty-four (24) hours but only if the amputation or loss of an eye occurs within twenty-four (24) hours of the incident.

Employers reporting a fatality, in-patient hospitalization, amputation, or loss of an eye to OSHA must report the following information:

Establishment name Location of the work-related incident Time of the work-related incident Type of reportable event (i.e., fatality, in-patient hospitalization, amputation or loss of an

eye) Number of employees who suffered the event Names of the employees who suffered the event Contact person and his or her phone number Brief description of the work-related incident

Employers do not have to report an event if it:

Resulted from a motor vehicle accident on a public street or highway, except in a construction work zone; employers must report the event if it happened in a construction work zone.

Occurred on a commercial or public transportation system (airplane, subway, bus, ferry, street car, light rail, train).

Occurred more than 30 days after the work-related incident in the case of a fatality or more than 24 hours after the work-related incident in the case of an in-patient hospitalization, amputation, or loss of an eye.

However, the above events need to be recorded on the facility’s OSHA injury and illness records, if the facility is required to keep OSHA injury and illness records. 

Employers do not have to report an in-patient hospitalization if it was for diagnostic testing or observation only. An in-patient hospitalization is defined as a formal admission to the in-patient service of a hospital or clinic for care or treatment.

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Employers do have to report an in-patient hospitalization due to a heart attack, if the heart attack resulted from a work-related incident.

Employers may report incidents as described above using one of the following three options:

1. Calling OSHA’s confidential, toll-free number: 1-800-321-OSHA (6742).2. Calling or visiting the closest OSHA area office. Pennsylvania area offices may be found

on the following website: https://www.osha.gov/oshdir/pa.html. The Pennsylvania regional office is located at:

U.S. Department of Labor/OSHAThe Curtis Center-Suite 740 West170 S. Independence Mall WestPhiladelphia, PA 19106-3309TELE: (215) 861-4900FAX: (215) 861-4904 

Area offices are located at:

Allentown Area Stabler Corporate Center3477 Corporate ParkwaySuite 120Center Valley, PA 18034(267) 429-7542(267) 429-7567 FAX

Erie Area 1128 State Street, Suite 200Erie, Pennsylvania 16501(814) 874-5150(814) 874-5151 FAX

Harrisburg Area 43 Kline PlazaHarrisburg, PA 17104-1529(717) 782-3902(717) 782-3746 FAX

Philadelphia Area U.S. Custom House, Room 242

Second & Chestnut StreetPhiladelphia, Pennsylvania 19106-2902(215) 597-4955(215) 597-1956 FAX

Pittsburgh Area U.S. Department of Labor-OSHAWilliam Moorhead Federal Building, Room 9051000 Liberty AvenuePittsburgh, PA 15222(412) 395-4903 (412) 395-6380 FAX

Wilkes-Barre Area The Stegmaier Building, Suite 4107 North Wilkes-Barre BoulevardWilkes-Barre, PA 18702-5241(570) 826-6538(570) 821-4170 FAX

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3. Submitting a report via the OSHA online reporting form located at https://www.osha/gov/recordkeeping.